List Archives

Fri Jan 5 18:26:48 GMT 2007

Dear All,

  I present a case and I would appreciate the opinions. It is not exactly trauma but a similar situation may arise in trauma.

  55yr old asian male, alcoholic, arrived in A&E in cardiogenic shock. He was recusitated with an Intra aortic Balloon, underwent emergency coronary stenting. 6 hours after the procedure the patient went hypotensive. He responded to fluids. However about an hour later ,the hypotension recurred. His left groin , the site of  the ballon insertion was explored with the possibility of fmoral arterial damage. Noe was found. At the same time the cardiac surgeon put a drain in his pertoeal cavity which initally exhibited ascitic fluid only.This happened near 10 pm.

  During the night the drain drained 3 litres of fresh blood. He was resuscitaed with 11PBC, 8 FFP's and 6 cryos. In the morning, a abdominal cat- scan, requested by the general surgeons showed free fluid in the peritoneum, with lack of contrast uptake by the peripheral hepatic regions. 

  He underwent a laparotomy, revealed a huge subcapsular hepatic hematoma in the preipheries of the right and the left lobe. 1.5 L of clots and blood was removed. The liver was packed and the abdomen closed

  The questions are as follows:-

  1. When can a drug like PLavix(clopidrogel) be started after such a procedure to save the stent?
  2. When should the packs be removed?
  3. How should the now partially empty preihepativ space be filled again ( ? omentum).

  Yours,

  Dr. Zunorain Dodhy
  Surgical Registrar.

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Today's Topics:

1. High Dose Mannitol (Coats Tim - Professor of Emergency Medicine)
2. Re: High Dose Mannitol (Rangraj Setlur)
3. Re: High Dose Mannitol (Guy Jackson)
4. Re: High Dose Mannitol (Ben Reynolds)
From: "Coats Tim - Professor of Emergency Medicine" <Tim.Coats at uhl-tr.nhs.uk>
Subject: High Dose Mannitol
Date: Thu, 4 Jan 2007 11:35:27 -0000
To: <trauma-list at trauma.org>

Dear all,

Prof Ian Roberts, who chairs the Cochrane Injuries Group, has asked me
to pass on the information below, which has led to the withdrawal of the
Cochrane review on high dose mannitol. Details are available on the
CRASH2 website.
My interpretation is that this is a sad story and that we will probably
never know the truth. However it does seem that the data in the three
published papers cannot be verified, greatly reducing the body of
evidence for high dose mannitol therapy.

Tim. Coats.
Professor of Emergency Medicine.
Leicester University

Dear Tim 
The Cochrane Injuries Group conducted an investigation into some head
injury trials by Cruz et al - the details should be of interest to the
trauma community. 
We have put the key correspondence on the trial website to make it
available to our collaborators but I wondered if you could let the folk
at trauma.org know about it as well. 
Between 2001 and 2004, three reports were published by Dr Julio Cruz and
colleagues presenting the results of three clinical trials comparing
high dose and conventional dose mannitol in the treatment of head
injury. They appeared to show that high dose mannitol was dramatically
effective in reducing death and disability after head injury. 
Cruz C, Minoja G, Okuchi K. Improving clinical outcomes from acute
subdural hematomas with emergency preoperative administration of high
doses of mannitol: a randomized trial. Neurosurgery 2001;49(4):864-71.
Cruz C, Minoja G, Okuchi K. Major clinical and physiological benefits of
early high doses of mannitol for intraparenchymal temporal lobe
hemorrhages with abnormal pupilary widening. Neurosurgery
2002;51(3):628-38.
Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose
mannitol treatment in patients with Glasgow Coma Scores of 3 and
bilateral abnormal pupillary widening: a randomized trial. Journal of
Neurosurgery 2004;100(3):376-83.
The trials were included in a systematic review of the effectiveness of
mannitol in head injury and published in the Cochrane Library in July
2005. The review concluded that "high dose mannitol appears to be
preferable to conventional dose mannitol in the acute management of
comatose patients with severe head injury." 
The Cochrane Injuries Group later discovered that there were concerns
about these trials and an investigation was made the results of which
are available on the CRASH-2 website (www.crash2.lshtm.ac.uk
). We know
that mannitol is widely used in the management of patients with head
trauma and felt that you should be made aware of the Injuries Group
investigation as soon as possible. Please pass this message on to your
colleagues in trauma care. 
Ian 

This e-mail, including any attached files, may contain confidential and / or privileged information and is intended for the exclusive use of the addressee(s) printed above. If you are not the addressee(s), any unauthorised review, disclosure, reproduction, other dissemination or use of this e-mail, or taking of any action in reliance upon the information contained herein, is strictly prohibited. If this e-mail has been sent to you in error, please return to the sender. No guarantee can be given that the contents of this email are virus free - The University Hospitals of Leicester NHS Trust cannot be held responsible for any failure by the recipient(s) to test for viruses before opening any attachments. The information contained in this e-mail may be the subject of public disclosure under the Freedom of Information Act 2000 - unless legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed. Copyright in this email and any
 attachments created by us remains vested in the University Hospitals of Leicester NHS Trust.

From: "Rangraj Setlur" <rangraj at gmail.com>
Subject: Re: High Dose Mannitol
Date: Thu, 4 Jan 2007 20:49:42 +0530
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>

I read the correspondence on http://www.crash2.lshtm.ac.uk/Mannitol.htm .Its
a little hard to understand what happened, do you have any further details
about the concerns of fabrication?
rangraj
On 1/4/07, Coats Tim - Professor of Emergency Medicine <
Tim.Coats at uhl-tr.nhs.uk> wrote:
>
> Dear all,
>
> Prof Ian Roberts, who chairs the Cochrane Injuries Group, has asked me
> to pass on the information below, which has led to the withdrawal of the
> Cochrane review on high dose mannitol. Details are available on the
> CRASH2 website.
> My interpretation is that this is a sad story and that we will probably
> never know the truth. However it does seem that the data in the three
> published papers cannot be verified, greatly reducing the body of
> evidence for high dose mannitol therapy.
>
> Tim. Coats.
> Professor of Emergency Medicine.
> Leicester University
>
> Dear Tim
> The Cochrane Injuries Group conducted an investigation into some head
> injury trials by Cruz et al - the details should be of interest to the
> trauma community.
> We have put the key correspondence on the trial website to make it
> available to our collaborators but I wondered if you could let the folk
> at trauma.org know about it as well.
> Between 2001 and 2004, three reports were published by Dr Julio Cruz and
> colleagues presenting the results of three clinical trials comparing
> high dose and conventional dose mannitol in the treatment of head
> injury. They appeared to show that high dose mannitol was dramatically
> effective in reducing death and disability after head injury.
> Cruz C, Minoja G, Okuchi K. Improving clinical outcomes from acute
> subdural hematomas with emergency preoperative administration of high
> doses of mannitol: a randomized trial. Neurosurgery 2001;49(4):864-71.
> Cruz C, Minoja G, Okuchi K. Major clinical and physiological benefits of
> early high doses of mannitol for intraparenchymal temporal lobe
> hemorrhages with abnormal pupilary widening. Neurosurgery
> 2002;51(3):628-38.
> Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose
> mannitol treatment in patients with Glasgow Coma Scores of 3 and
> bilateral abnormal pupillary widening: a randomized trial. Journal of
> Neurosurgery 2004;100(3):376-83.
> The trials were included in a systematic review of the effectiveness of
> mannitol in head injury and published in the Cochrane Library in July
> 2005. The review concluded that "high dose mannitol appears to be
> preferable to conventional dose mannitol in the acute management of
> comatose patients with severe head injury."
> The Cochrane Injuries Group later discovered that there were concerns
> about these trials and an investigation was made the results of which
> are available on the CRASH-2 website (www.crash2.lshtm.ac.uk
> ). We know
> that mannitol is widely used in the management of patients with head
> trauma and felt that you should be made aware of the Injuries Group
> investigation as soon as possible. Please pass this message on to your
> colleagues in trauma care.
> Ian
>
>
> This e-mail, including any attached files, may contain confidential and /
> or privileged information and is intended for the exclusive use of the
> addressee(s) printed above. If you are not the addressee(s), any
> unauthorised review, disclosure, reproduction, other dissemination or use of
> this e-mail, or taking of any action in reliance upon the information
> contained herein, is strictly prohibited. If this e-mail has been sent to
> you in error, please return to the sender. No guarantee can be given that
> the contents of this email are virus free - The University Hospitals of
> Leicester NHS Trust cannot be held responsible for any failure by the
> recipient(s) to test for viruses before opening any attachments. The
> information contained in this e-mail may be the subject of public disclosure
> under the Freedom of Information Act 2000 - unless legally exempt from
> disclosure, the confidentiality of this e-mail and your reply cannot be
> guaranteed. Copyright in this email and any attachments created by us
> remains vested in the University Hospitals of Leicester NHS Trust.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
>

From: "Guy Jackson" <r.g.m.jackson at qmul.ac.uk>
Subject: Re: High Dose Mannitol
Date: Thu, 4 Jan 2007 15:26:10 -0000
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>

Tim,

Sad indeed.

The question is: should this change management? My guess is not for many of
us, as we don't use this much acutely anyway. The trouble is the lack of
data (now even worse) for therapies that come from the age when new ones
could be introduced without proper RCTs. Perhaps the best outcome from this
sorry episode might be called CRASH 3?

Guy Jackson
London, UK

----- Original Message ----- 
From: "Coats Tim - Professor of Emergency Medicine"

To: 
Sent: Thursday, January 04, 2007 11:35 AM
Subject: High Dose Mannitol

Dear all,

Prof Ian Roberts, who chairs the Cochrane Injuries Group, has asked me
to pass on the information below, which has led to the withdrawal of the
Cochrane review on high dose mannitol. Details are available on the
CRASH2 website.
My interpretation is that this is a sad story and that we will probably
never know the truth. However it does seem that the data in the three
published papers cannot be verified, greatly reducing the body of
evidence for high dose mannitol therapy.

Tim. Coats.
Professor of Emergency Medicine.
Leicester University

Dear Tim
The Cochrane Injuries Group conducted an investigation into some head
injury trials by Cruz et al - the details should be of interest to the
trauma community.
We have put the key correspondence on the trial website to make it
available to our collaborators but I wondered if you could let the folk
at trauma.org know about it as well.
Between 2001 and 2004, three reports were published by Dr Julio Cruz and
colleagues presenting the results of three clinical trials comparing
high dose and conventional dose mannitol in the treatment of head
injury. They appeared to show that high dose mannitol was dramatically
effective in reducing death and disability after head injury.
Cruz C, Minoja G, Okuchi K. Improving clinical outcomes from acute
subdural hematomas with emergency preoperative administration of high
doses of mannitol: a randomized trial. Neurosurgery 2001;49(4):864-71.
Cruz C, Minoja G, Okuchi K. Major clinical and physiological benefits of
early high doses of mannitol for intraparenchymal temporal lobe
hemorrhages with abnormal pupilary widening. Neurosurgery
2002;51(3):628-38.
Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose
mannitol treatment in patients with Glasgow Coma Scores of 3 and
bilateral abnormal pupillary widening: a randomized trial. Journal of
Neurosurgery 2004;100(3):376-83.
The trials were included in a systematic review of the effectiveness of
mannitol in head injury and published in the Cochrane Library in July
2005. The review concluded that "high dose mannitol appears to be
preferable to conventional dose mannitol in the acute management of
comatose patients with severe head injury."
The Cochrane Injuries Group later discovered that there were concerns
about these trials and an investigation was made the results of which
are available on the CRASH-2 website (www.crash2.lshtm.ac.uk
). We know
that mannitol is widely used in the management of patients with head
trauma and felt that you should be made aware of the Injuries Group
investigation as soon as possible. Please pass this message on to your
colleagues in trauma care.
Ian

This e-mail, including any attached files, may contain confidential and /
or privileged information and is intended for the exclusive use of the
addressee(s) printed above. If you are not the addressee(s), any
unauthorised review, disclosure, reproduction, other dissemination or use of
this e-mail, or taking of any action in reliance upon the information
contained herein, is strictly prohibited. If this e-mail has been sent to
you in error, please return to the sender. No guarantee can be given that
the contents of this email are virus free - The University Hospitals of
Leicester NHS Trust cannot be held responsible for any failure by the
recipient(s) to test for viruses before opening any attachments. The
information contained in this e-mail may be the subject of public disclosure
under the Freedom of Information Act 2000 - unless legally exempt from
disclosure, the confidentiality of this e-mail and your reply cannot be
guaranteed. Copyright in this email and any attachments created by us
remains vested in the University Hospitals of Leicester NHS Trust.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

From: Ben Reynolds <aneurysm_42 at yahoo.com>
Subject: Re: High Dose Mannitol
Date: Thu, 4 Jan 2007 11:00:14 -0800 (PST)
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>

This shouldn't be an indictment of the premise, only
of (allegedly) the actions of one group.

The Cochrane link sent by Rangraj was both
enlightening and saddening all at once.

Ben Reynolds, PA-C
Pittsburgh, PA

--- Guy Jackson wrote:

> Tim,
> 
> Sad indeed.
> 
> The question is: should this change management? My
> guess is not for many of
> us, as we don't use this much acutely anyway. The
> trouble is the lack of
> data (now even worse) for therapies that come from
> the age when new ones
> could be introduced without proper RCTs. Perhaps the
> best outcome from this
> sorry episode might be called CRASH 3?
> 
> Guy Jackson
> London, UK
> 
> 
> ----- Original Message ----- 
> From: "Coats Tim - Professor of Emergency Medicine"
> 
> To: 
> Sent: Thursday, January 04, 2007 11:35 AM
> Subject: High Dose Mannitol
> 
> 
> Dear all,
> 
> Prof Ian Roberts, who chairs the Cochrane Injuries
> Group, has asked me
> to pass on the information below, which has led to
> the withdrawal of the
> Cochrane review on high dose mannitol. Details are
> available on the
> CRASH2 website.
> My interpretation is that this is a sad story and
> that we will probably
> never know the truth. However it does seem that the
> data in the three
> published papers cannot be verified, greatly
> reducing the body of
> evidence for high dose mannitol therapy.
> 
> Tim. Coats.
> Professor of Emergency Medicine.
> Leicester University
> 
> Dear Tim
> The Cochrane Injuries Group conducted an
> investigation into some head
> injury trials by Cruz et al - the details should be
> of interest to the
> trauma community.
> We have put the key correspondence on the trial
> website to make it
> available to our collaborators but I wondered if you
> could let the folk
> at trauma.org know about it as well.
> Between 2001 and 2004, three reports were published
> by Dr Julio Cruz and
> colleagues presenting the results of three clinical
> trials comparing
> high dose and conventional dose mannitol in the
> treatment of head
> injury. They appeared to show that high dose
> mannitol was dramatically
> effective in reducing death and disability after
> head injury.
> Cruz C, Minoja G, Okuchi K. Improving clinical
> outcomes from acute
> subdural hematomas with emergency preoperative
> administration of high
> doses of mannitol: a randomized trial. Neurosurgery
> 2001;49(4):864-71.
> Cruz C, Minoja G, Okuchi K. Major clinical and
> physiological benefits of
> early high doses of mannitol for intraparenchymal
> temporal lobe
> hemorrhages with abnormal pupilary widening.
> Neurosurgery
> 2002;51(3):628-38.
> Cruz J, Minoja G, Okuchi K, Facco E. Successful use
> of the new high-dose
> mannitol treatment in patients with Glasgow Coma
> Scores of 3 and
> bilateral abnormal pupillary widening: a randomized
> trial. Journal of
> Neurosurgery 2004;100(3):376-83.
> The trials were included in a systematic review of
> the effectiveness of
> mannitol in head injury and published in the
> Cochrane Library in July
> 2005. The review concluded that "high dose mannitol
> appears to be
> preferable to conventional dose mannitol in the
> acute management of
> comatose patients with severe head injury."
> The Cochrane Injuries Group later discovered that
> there were concerns
> about these trials and an investigation was made the
> results of which
> are available on the CRASH-2 website
> (www.crash2.lshtm.ac.uk
>

> ). We know
> that mannitol is widely used in the management of
> patients with head
> trauma and felt that you should be made aware of the
> Injuries Group
> investigation as soon as possible. Please pass this
> message on to your
> colleagues in trauma care.
> Ian
> 
> 
> This e-mail, including any attached files, may
> contain confidential and /
> or privileged information and is intended for the
> exclusive use of the
> addressee(s) printed above. If you are not the
> addressee(s), any
> unauthorised review, disclosure, reproduction, other
> dissemination or use of
> this e-mail, or taking of any action in reliance
> upon the information
> contained herein, is strictly prohibited. If this
> e-mail has been sent to
> you in error, please return to the sender. No
> guarantee can be given that
> the contents of this email are virus free - The
> University Hospitals of
> Leicester NHS Trust cannot be held responsible for
> any failure by the
> recipient(s) to test for viruses before opening any
> attachments. The
> information contained in this e-mail may be the
> subject of public disclosure
> under the Freedom of Information Act 2000 - unless
> legally exempt from
> disclosure, the confidentiality of this e-mail and
> your reply cannot be
> guaranteed. Copyright in this email and any
> attachments created by us
> remains vested in the University Hospitals of
> Leicester NHS Trust.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
> 
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
> 

--
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