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Fri Feb 15 00:19:59 GMT 2008

We are moving to 1:1:1 transfusion for the bad bleeders and firmly believe it reduces the amount of fVIIa we need to give for those circumstances were we just get too far behind in the transfusion of factors. But I don't really know what endpoints should initiate a 1:1:1 policy, as opposed to just giving 3 or 4 red cells, are seeing what happens (refractory hypotension?, lactate?). Unless we figure out something sensible it will be our next area of irrational exuberance!
Has anyone come up what triggers a change the release policy to 1:1:1?

Cheers   

Kerry
Dr Kerry Gunn MBChB DA(UK) FANZCA
Department of Anaesthesia and Perioperative Medicine
Auckland City Hospital
Auckland
ph +64 9 3797440 ext 7505
fax+64 9 3072814
mob +64 21 427626

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-----Original Message-----
From: trauma-list-bounces at trauma.org on behalf of trauma-list-request at trauma.org
Sent: Fri 2/15/2008 12:07 PM
To: trauma-list at trauma.org
Subject: trauma-list Digest, Vol 56, Issue 16

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Today's Topics:

   1. RE: Who's doing 1:1 blood transfusions for shock?
      (Hardcastle, Tim, Dr <tch at sun.ac.za>)
   2. 1:1 Blood Resuscitation, Round 2. (Sise, Mike MD)
   3. Re: 1:1 Blood Resuscitation, Round 2. (KMATTOX at aol.com)
   4. Re: trauma-list Digest, Vol 56, Issue 15
      (stephengrant at comcast.net)
   5. Re: 1:1 Blood Resuscitation, Round 2. (htaed_rd at 123mail.org)
   6. Re: CT confirmation of healing spleen (SJASMD at aol.com)
   7. Re: 1:1 Blood Resuscitation, Round 2. (Ronald Gross)
   8. Re: 1:1 Blood Resuscitation, Round 2. (Ronald Gross)
   9. Re: CT confirmation of healing spleen (Ronald Gross)
  10. Re: 1:1 Blood Resuscitation, Round 2. (htaed_rd at 123mail.org)
  11. Re: 1:1 Blood Resuscitation, Round 2. (Ronald Gross)
  12. RE: Who's doing 1:1 blood transfusions for shock? (Bjorn, Pret)

----------------------------------------------------------------------

Message: 1
Date: Thu, 14 Feb 2008 14:01:37 +0200
From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
Subject: RE: Who's doing 1:1 blood transfusions for shock?
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
	<3FE6F2A76FE75C418D3E0481CD75EA1E58B0A4 at TYGEVS01.tyg.sun.ac.za>
Content-Type: text/plain;	charset="iso-8859-1"

Karim

An old addage says that if you aim at nothing - you're sure to hit it.

With the 1:1:1 philosophy if we aim to get the FFP & PLT in to the bleeding patient as soon as possible we may just prevent the complications of the coagulopathy than if we tried to play catch-up later after the massive red-cell only transfusion.

My thought therefore is that by getting the blood bank "on the go" to get the products will end up with something of the comprimise you advocate: somewhere between 1:1 and 1:3 or 4. Some is still better than none.

Also there is more evidence out there for this than just the trials you mention!

My 2c of personal bias
tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Karim Brohi
Sent: Wednesday, February 13, 2008 1:42 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Who's doing 1:1 blood transfusions for shock?

<<  It has NOT been universally accepted, however, and I am not sure why. >>
Ron

Because one swallow doesn't make a spring, and one retrospective military
study shouldn't change global practice.

Most of the evidence of effect lies in those patients that are significantly
under-treated - those that receive no plasma or ratios below 1:4.  There is
less effect in lowering the ratio below 1:4.  Some studies show benefit,
some no effect, some worse outcome (see paper from Denver at last year's
AAST).

There are huge potential for bias and confounding factors in these
retrospective studies.  Gonzalez has shown that patients who are really
bleeding are more likely to fall below the desired transfusion algorithm
(whichever is being used).  Those patients who are sickest are more likely
to get lower ratios, as teams struggle to keep up with the haemorrhage and
plasma is delivered slower than red cells.

Those of you who anecdotally believe that less transfusions are used are not
supported by the data, which suggest that an equal amount of products are
used in each group within the first 24 hours.  Whatever the mechanism, it's
not clear that the actual number of blood products administered is different
between groups.

The evidence for platelets is even shakier (read non-existent).  Especially
if you believe in plasma, because the volume of plasma that the platelets
are stored in could potentially completely explain the platelet effect.

There are significant implications for providing 1:1 plasma instead of 1:3 -
more use of AB plasma, increased risks, increased work for transfusion
staff, increased likelihood of error, and inability to keep up (Par
Johansson, a world-class transfusionist in Copenhagen has been running 1:1
for years and has modelled resource provision.  He is clear that provision
of 1:1 ratios during multiple casualty events is almost impossible).

Now I'm not saying that 1:1 is not the right thing to do.   It may be, but
we have a suggestion of effect and that is all at present.  Read the
Cochrane review on plasma therapy - for any indication.  There's so little
evidence out there it behoves us to investigate this more thoroughly before
we expose our patients to 3-4 times the dose of a product we have little
knowledge of.

Sadly I'm speaking 'For' 1:1 in Vegas - which is much easier and more boring
:-)

Karim

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------------------------------

Message: 2
Date: Thu, 14 Feb 2008 06:03:48 -0800
From: "Sise, Mike MD" <Sise.Mike at scrippshealth.org>
Subject: 1:1 Blood Resuscitation, Round 2.
To: trauma-list at trauma.org
Message-ID:
	<FEECA018557C774EB876F0D3BCB54E1B01103A58 at MSG02.corp.scripps.org>
Content-Type: text/plain; charset=iso-8859-1

So there is controversy over 1:1. How do we answer the question? Is a randomized trial justified or is it promising enough to just do it? On the one hand, we spent over 40 years using the intellectually attractive "balanced salt solution" lactated ringers without examining its impact. And blood transfusion therapy during the same interval may have been dictated by the technology that allowed fractionated blood banking - we abandoned whole blood. On the other hand, the results of 1:1 appear extremely promising. Pre-treatment Informed consent will be out of the question. Soooo, how about it Ken, Karim, Ron, Tim, all you trauma.org-istas.

Mike Sise
San Diego

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Message: 3
Date: Thu, 14 Feb 2008 09:23:18 EST
From: KMATTOX at aol.com
Subject: Re: 1:1 Blood Resuscitation, Round 2.
To: trauma-list at trauma.org
Message-ID: <c96.1f3f04cb.34e5a8d6 at aol.com>
Content-Type: text/plain; charset="US-ASCII"

Randomized Trial.   Waiver of Consent.     Cakewalk

k

In a message dated 2/14/2008 8:05:26 A.M. Central Standard Time,  
Sise.Mike at scrippshealth.org writes:

Informed  consent will be out of the  question

**************The year's hottest artists on the red carpet at the Grammy 
Awards. Go to AOL Music.      
(http://music.aol.com/grammys?NCID=aolcmp00300000002565)

------------------------------

Message: 4
Date: Thu, 14 Feb 2008 14:57:45 +0000
From: stephengrant at comcast.net
Subject: Re: trauma-list Digest, Vol 56, Issue 15
To: trauma-list at trauma.org
Message-ID:
	<021420081457.16644.47B456E900097FD30000410422007601809B020E9D09020A089F0A9B9C at comcast.net>

Content-Type: text/plain

please remove this e-mail address from the list server.

--
J. Stephen Grant, MS, RN, CEN, EMT-P 
Voice - (904) 866-8098 
Fax - (904) 268-5271

-------------- Original message -------------- 
From: trauma-list-request at trauma.org 

> Send trauma-list mailing list submissions to 
> trauma-list at trauma.org 
> 
> To subscribe or unsubscribe via the World Wide Web, visit 
> http://list.mistral.net/mailman/listinfo/trauma-list 
> or, via email, send a message with subject or body 'help' to 
> trauma-list-request at trauma.org 
> 
> You can reach the person managing the list at 
> trauma-list-owner at trauma.org 
> 
> When replying, please edit your Subject line so it is more specific 
> than "Re: Contents of trauma-list digest..." 
> 
> 
> Today's Topics: 
> 
> 1. RE: Who's doing 1:1 blood transfusions for shock? 
> (William Bromberg) 
> 2. Re: Who's doing 1:1 blood transfusions for shock? AND WHY 
> (KMATTOX at aol.com) 
> 3. 1:1 blood transfusions for shock (Christos Giannou) 
> 4. RE: CT confirmation of healing spleen (tina) 
> 5. Re: CT confirmation of healing spleen (SJASMD at aol.com) 
> 6. Re: CT confirmation of healing spleen (SJASMD at aol.com) 
> 7. Re: CT confirmation of healing spleen (SJASMD at aol.com) 
> 8. Re: (no subject) (SJASMD at aol.com) 
> 9. Re: CT confirmation of healing spleen (SJASMD at aol.com) 
> 10. RE: CT confirmation of healing spleen (tina) 
> 11. RE: CT confirmation of healing spleen (Ronald Gross) 
> 12. Re: CT confirmation of healing spleen (Ronald Gross) 
> 13. Re: CT confirmation of healing spleen (Ronald Gross) 
> 
> 
> ---------------------------------------------------------------------- 
> 
> Message: 1 
> Date: Wed, 13 Feb 2008 08:28:49 -0500 
> From: "William Bromberg" 
> Subject: RE: Who's doing 1:1 blood transfusions for shock? 
> To: "'Trauma & Critical Care mailing list'" 
> 
> Message-ID: <47B2AA41.85AB.003A.0 at memorialhealth.com> 
> Content-Type: text/plain; charset=US-ASCII 
> 
> Also, have you all seen the new whitepaper from the transfusion medicine people 
> about TRALI and the use of female plasma? It looks like the plasma supply just 
> got cut in half more or less. The link is from the lay press (but not a bad 
> article). 
> 
> http://www.sptimes.com/2007/01/23/Worldandnation/Lung_injury_tied_to_f.shtml 
> 
> Bill 
> 
> >>> "Karim Brohi" 2/12/2008 6:41 PM >>> 
> << It has NOT been universally accepted, however, and I am not sure why. >> 
> Ron 
> 
> Because one swallow doesn't make a spring, and one retrospective military 
> study shouldn't change global practice. 
> 
> 
> 
> There are significant implications for providing 1:1 plasma instead of 1:3 - 
> more use of AB plasma, increased risks, increased work for transfusion 
> staff, increased likelihood of error, and inability to keep up (Par 
> Johansson, a world-class transfusionist in Copenhagen has been running 1:1 
> for years and has modelled resource provision. He is clear that provision 
> of 1:1 ratios during multiple casualty events is almost impossible). 
> 
> Now I'm not saying that 1:1 is not the right thing to do. It may be, but 
> we have a suggestion of effect and that is all at present. Read the 
> Cochrane review on plasma therapy - for any indication. There's so little 
> evidence out there it behoves us to investigate this more thoroughly before 
> we expose our patients to 3-4 times the dose of a product we have little 
> knowledge of. 
> 
> Sadly I'm speaking 'For' 1:1 in Vegas - which is much easier and more boring 
> :-) 
> 
> Karim 
> 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> 
> 
> ------------------------------ 
> 
> Message: 2 
> Date: Wed, 13 Feb 2008 08:36:43 EST 
> From: KMATTOX at aol.com 
> Subject: Re: Who's doing 1:1 blood transfusions for shock? AND WHY 
> To: trauma-list at trauma.org 
> Message-ID: 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> I know the course director - ME 
> I know the moderator of THE DEBATE - Mike Sise 
> I know the debaters - Karim and Dr. Wisner from Sacramento 
> I have seen their scripts. 
> YES, I agree. It will be a great session, and I don't really know who will 
> will win. It will all be in the delivery. You MUST not miss this debate 
> and the other 50 presentations of this conference. 
> I do know that even two weeks before the close of EARLY registration we are 
> already discussing when we might close the registration as being over 
> subscribed. We we summarizing and projecting closure dates just yesterday. 
> SOOOOOOOOOO 
> 
> 
> In a message dated 2/13/2008 1:59:27 A.M. Central Standard Time, 
> karim at trauma.org writes: 
> 
> Totally agree - it'll be a great session. _www.trauma-criticalcare.com_ 
> (http://www.trauma-criticalcare.com/) 
> And I'm going to win. 
> K 
> 
> -----Original Message----- 
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
> On Behalf Of Ronald Gross 
> Sent: 13 February 2008 00:59 
> To: trauma-list at trauma.org 
> Subject: RE: Who's doing 1:1 blood transfusions for shock? 
> 
> "Sadly I'm speaking 'For' 1:1 in Vegas - which is much easier and more 
> boring" 
> 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> 
> 
> ------------------------------ 
> 
> Message: 3 
> Date: Wed, 13 Feb 2008 17:41:39 +0200 
> From: "Christos Giannou" 
> Subject: 1:1 blood transfusions for shock 
> To: trauma-list at trauma.org 
> Message-ID: 
> <64c08ba00802130741n16a301b7g74401542d69bc800 at mail.gmail.com> 
> Content-Type: text/plain; charset=ISO-8859-1 
> 
> I understand your concerns Karim, especially concerning one retrospective 
> military study, but a small note of caution when one speaks of "global 
> practice". 
> 
> Many hospitals in the world (the majority?) do not have access to blood 
> components. For many of us, the standard is whole blood, as fresh as 
> possible, and usually donated by a family member. I understand that what is 
> under discussion is practice in the industrialised world -- and certain 
> capital cities of the Third World -- but would also mention that recent 
> "military studies" from Iraq and Afghanistan have also extolled the benefits 
> of fresh whole blood for shock. 
> 
> One idea might be to start swinging the pendulum back a bit. I imagine there 
> is a whole cohort of senior, not to say elderly, surgeons on the list who 
> started their practice using whole blood, in glass bottles! (Wonderful piece 
> of equipment to have around for autotransfusion.) Perhaps some basic 
> research in an antiquated pre-blood-component technique would be in order. 
> Our colleagues in the industrialised world would have to help us out, 
> however. Not a simple task to do much research in a bush hospital, although 
> the US military is trying with their forward surgical teams. 
> 
> best regards, 
> 
> -- 
> chris giannou 
> senior surgeon 
> international committee of the red cross 
> Monemvasia Lakonia 
> 23070 Greece 
> 
> 
> ------------------------------ 
> 
> Message: 4 
> Date: Wed, 13 Feb 2008 22:31:18 +0100 
> From: "tina" 
> Subject: RE: CT confirmation of healing spleen 
> To: "'Trauma & Critical Care mailing list'" 
> 
> Message-ID: <000101c86e87$c568a8f0$5039fad0$@no> 
> Content-Type: text/plain; charset="us-ascii" 
> 
> Agree with Tim...comments so far seem to sum up nicely what we know about 
> follow-up after splenic injuries...very little. Even with a CT like this, 
> most would let him go back to unrestricted activity if he is otherwise 
> fine...so is there a place for late follow-up CT scans in clinically 
> restituted patients? Also I don't know of any evidence for restricting 
> activity 6 months? 
> 
> We stopped doing late follow-up CT scans for splenic injuries a few years 
> ago..as we often ended up worrying about the CT appearance, however still 
> letting the patient go back to unrestricted activity after 8-12 weeks if 
> feeling ok, 12 weeks for grade 4/5, no evidence.. 
> 
> Tina Gaarder 
> Oslo 
> 
> -----Original Message----- 
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
> On Behalf Of Hardcastle, Tim, Dr 
> Sent: 13. februar 2008 06:01 
> To: Trauma & Critical Care mailing list 
> Subject: RE: CT confirmation of healing spleen 
> 
> Allen 
> 
> Since folow-up CT does not predict failure, I'm not sure about whether it 
> should have been done, but since he is well and likely to have a new capsule 
> - sure, why not! 
> 
> Tim 
> 
> -----Original Message----- 
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of 
> gsuywy at pacific.net.sg 
> Sent: Tuesday, February 12, 2008 6:31 PM 
> To: Trauma & Critical Care mailing list 
> Subject: CT confirmation of healing spleen 
> 
> 
> Dear all 
> I would appreciate the opinion of the members on the CT confirmation 
> of a healed ruptured spleen. The CT scan is of a 20 year old male 
> injured in a MVC - initial CT showing a splenic injury managed 
> conservatively and another 6 months later showing a ? fibrous band 
> joining the 2 fragments. 
> 
> Is this sufficient evidence to allow him to go back to contact sports? 
> Or is the band expected to narrow even further in the future? 
> 
> Thanks very much 
> 
> Allen 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> 
> 
> ------------------------------ 
> 
> Message: 5 
> Date: Thu, 14 Feb 2008 01:24:59 EST 
> From: SJASMD at aol.com 
> Subject: Re: CT confirmation of healing spleen 
> To: trauma-list at trauma.org 
> Message-ID: 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> 
> In a message dated 2/12/2008 5:32:44 P.M. W. Europe Standard Time, 
> gsuywy at pacific.net.sg writes: 
> 
> Dear all 
> I would appreciate the opinion of the members on the CT confirmation 
> of a healed ruptured spleen. The CT scan is of a 20 year old male 
> injured in a MVC - initial CT showing a splenic injury managed 
> conservatively and another 6 months later showing a ? fibrous band 
> joining the 2 fragments. 
> 
> Is this sufficient evidence to allow him to go back to contact sports? 
> Or is the band expected to narrow even further in the future? 
> 
> Thanks very much 
> 
> Allen 
> 
> 
> 
> no it is not evidence predictive of anything. 
> 
> Looks healed though. I would manage as if this were healed even if there 
> were no scan 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> 
> 
> ------------------------------ 
> 
> Message: 6 
> Date: Thu, 14 Feb 2008 01:25:52 EST 
> From: SJASMD at aol.com 
> Subject: Re: CT confirmation of healing spleen 
> To: trauma-list at trauma.org 
> Message-ID: 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> 
> In a message dated 2/12/2008 6:03:55 P.M. W. Europe Standard Time, 
> Rgross at harthosp.org writes: 
> 
> Allen, 
> 
> Even in the absence of a blush on this cut, I am amazed that you got away 
> with this!! Now, having said that, I would personally let the kid go back to 
> contact sports. 
> 
> Ron 
> 
> 
> 
> ron 
> 
> ive treated far worse conservatively with uneventful outcomes 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> 
> 
> ------------------------------ 
> 
> Message: 7 
> Date: Thu, 14 Feb 2008 01:30:07 EST 
> From: SJASMD at aol.com 
> Subject: Re: CT confirmation of healing spleen 
> To: trauma-list at trauma.org 
> Message-ID: 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> 
> In a message dated 2/12/2008 8:17:32 P.M. W. Europe Standard Time, 
> Rgross at harthosp.org writes: 
> 
> Hey Sal, are you out there? Have you seen this kind of defect on a healed 
> spleen? 
> 
> >>> "Ronald Simon" 2/12/2008 12:31 PM >>> 
> Yea, i know....... BUT, as you said, that was quite the crack to begin with. 
> Personally, i have never seen such a large remaining defect. That said, i 
> learn and see new stuff everyday. 
> ron 
> 
> 
> just catching up. 
> 
> we have seen patients who ended up healing two separate splenic segments do 
> very well, and our patients have some interesting "contact" sports to contend 
> with 
> 
> however i must remind that we do empiric angiography and will embolize 
> anyone with a angiographic blush. So our experience is kind of different. 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> 
> 
> ------------------------------ 
> 
> Message: 8 
> Date: Thu, 14 Feb 2008 01:38:08 EST 
> From: SJASMD at aol.com 
> Subject: Re: (no subject) 
> To: trauma-list at trauma.org 
> Message-ID: 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> 
> i might have mentioned this a long time ago but let me share this 
> utilization review nightmare with you all. 
> 
> when we started doing nonop management in 1978 based upon angiographic 
> findings, we kept all patients in the hospital until the injuries healed 
> substantially on 
> CT scans done TWO WEEKS apart. Longest hospitalization was about twelve 
> weeks, most healed within 2-6 weeks. About 30% of patients underwent 
> embolization. 
> 
> in those days in a municipal hospital, no one questioned it at all. 
> 
> Never had any rebleeds. 
> 
> Sounds ridiculous but that seemed reasonable back then as an alternative to 
> splenectomy. 
> 
> Thankfully reason has set in and we send our patients home in 3-5 days., 
> Don't reangio, don't CT, don't waste so much money 
> 
> sal 
> 
> In a message dated 2/12/2008 7:18:38 P.M. W. Europe Standard Time, 
> djinmori at terra.com.br writes: 
> 
> Hi Allen 
> 
> We have been followed our non-operative management of splenic and/or hepatic 
> trauma patients since 1993. Early 
> phase we have "taken care" these patients closer and we have let them out of 
> their activities. Nowadays we 
> allow then to return to their lives after 4 to 6 weeks just after we check a 
> new image study (sometimes US or 
> CT-scan) 
> 
> The next question would be: how sure we would be about splenic function? 
> Probably a novell of opinions 
> 
> And finally, if we are not able to confirm the splenic function, is it 
> necessary to prevent of post-splenectomy 
> sepsis? 
> 
> Nice case. 
> 
> 
> Surgical Emergency Service 
> Hospital das Clinicas - Sao Paulo - Brazil 
> MD Newton Djin Mori 
> djinmori at terra.com.br 
> 
> 
> 
> 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> 
> 
> ------------------------------ 
> 
> Message: 9 
> Date: Thu, 14 Feb 2008 01:41:42 EST 
> From: SJASMD at aol.com 
> Subject: Re: CT confirmation of healing spleen 
> To: trauma-list at trauma.org 
> Message-ID: 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> 
> In a message dated 2/13/2008 10:32:01 P.M. W. Europe Standard Time, 
> tinagaar at online.no writes: 
> 
> Agree with Tim...comments so far seem to sum up nicely what we know about 
> follow-up after splenic injuries...very little. Even with a CT like this, 
> most would let him go back to unrestricted activity if he is otherwise 
> fine...so is there a place for late follow-up CT scans in clinically 
> restituted patients? 
> 
> 
> 1.development of esophageal varices 
> 2. bruit 
> 3. persistent pain 
> 4. persistent anemia 
> 5. 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> 
> 
> ------------------------------ 
> 
> Message: 10 
> Date: Thu, 14 Feb 2008 08:01:02 +0100 
> From: "tina" 
> Subject: RE: CT confirmation of healing spleen 
> To: "'Trauma & Critical Care mailing list'" 
> 
> Message-ID: <000601c86ed7$5cbaa920$162ffb60$@no> 
> Content-Type: text/plain; charset="US-ASCII" 
> 
> Fully agree and thank you for the clarification...:-) however, those would 
> in my mind mostly be the non-restituted ones, ie the patients presenting at 
> follow-up with some kind of symptoms or reduced function (except for the 
> bruit) and thus qualify for CT scan. 
> 
> Tina 
> -----Original Message----- 
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
> On Behalf Of SJASMD at aol.com 
> Sent: 14. februar 2008 07:42 
> To: trauma-list at trauma.org 
> Subject: Re: CT confirmation of healing spleen 
> 
> 
> In a message dated 2/13/2008 10:32:01 P.M. W. Europe Standard Time, 
> tinagaar at online.no writes: 
> 
> Agree with Tim...comments so far seem to sum up nicely what we know about 
> follow-up after splenic injuries...very little. Even with a CT like this, 
> most would let him go back to unrestricted activity if he is otherwise 
> fine...so is there a place for late follow-up CT scans in clinically 
> restituted patients? 
> 
> 
> 1.development of esophageal varices 
> 2. bruit 
> 3. persistent pain 
> 4. persistent anemia 
> 5. 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> 
> 
> ------------------------------ 
> 
> Message: 11 
> Date: Thu, 14 Feb 2008 06:44:56 -0500 
> From: "Ronald Gross" 
> Subject: RE: CT confirmation of healing spleen 
> To: "'Trauma & Critical Care mailing list'" 
> 
> Message-ID: <47B3E368.7FF1.00B9.0 at harthosp.org> 
> Content-Type: text/plain; charset=US-ASCII 
> 
> Tina, 
> 
> I am there with you. In my practice, if we were lucky enough to have gotten 
> away with non-op therapy, a spleen looking like the original one projected would 
> remain in an athlete who would be out of the game till the next season, without 
> a f/u CT scan. 
> 
> Ron 
> >>> "tina" 2/13/2008 4:31 PM >>> 
> Agree with Tim...comments so far seem to sum up nicely what we know about 
> follow-up after splenic injuries...very little. Even with a CT like this, 
> most would let him go back to unrestricted activity if he is otherwise 
> fine...so is there a place for late follow-up CT scans in clinically 
> restituted patients? Also I don't know of any evidence for restricting 
> activity 6 months? 
> 
> We stopped doing late follow-up CT scans for splenic injuries a few years 
> ago..as we often ended up worrying about the CT appearance, however still 
> letting the patient go back to unrestricted activity after 8-12 weeks if 
> feeling ok, 12 weeks for grade 4/5, no evidence.. 
> 
> Tina Gaarder 
> Oslo 
> 
> -----Original Message----- 
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
> On Behalf Of Hardcastle, Tim, Dr 
> Sent: 13. februar 2008 06:01 
> To: Trauma & Critical Care mailing list 
> Subject: RE: CT confirmation of healing spleen 
> 
> Allen 
> 
> Since folow-up CT does not predict failure, I'm not sure about whether it 
> should have been done, but since he is well and likely to have a new capsule 
> - sure, why not! 
> 
> Tim 
> 
> -----Original Message----- 
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of 
> gsuywy at pacific.net.sg 
> Sent: Tuesday, February 12, 2008 6:31 PM 
> To: Trauma & Critical Care mailing list 
> Subject: CT confirmation of healing spleen 
> 
> 
> Dear all 
> I would appreciate the opinion of the members on the CT confirmation 
> of a healed ruptured spleen. The CT scan is of a 20 year old male 
> injured in a MVC - initial CT showing a splenic injury managed 
> conservatively and another 6 months later showing a ? fibrous band 
> joining the 2 fragments. 
> 
> Is this sufficient evidence to allow him to go back to contact sports? 
> Or is the band expected to narrow even further in the future? 
> 
> Thanks very much 
> 
> Allen 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> 
> ------------------------------ 
> 
> Message: 12 
> Date: Thu, 14 Feb 2008 06:51:34 -0500 
> From: "Ronald Gross" 
> Subject: Re: CT confirmation of healing spleen 
> To: 
> Message-ID: <47B3E4F6.7FF1.00B9.0 at harthosp.org> 
> Content-Type: text/plain; charset=US-ASCII 
> 
> Sal, 
> 
> I am pretty sure we all have - but not without significant "sphincter 
> tightening"! ;-) 
> 
> Best wishes, 
> Ron 
> 
> 
> 
> >>> 2/14/2008 1:25 AM >>> 
> 
> In a message dated 2/12/2008 6:03:55 P.M. W. Europe Standard Time, 
> Rgross at harthosp.org writes: 
> 
> Allen, 
> 
> Even in the absence of a blush on this cut, I am amazed that you got away 
> with this!! Now, having said that, I would personally let the kid go back to 
> contact sports. 
> 
> Ron 
> 
> 
> 
> ron 
> 
> ive treated far worse conservatively with uneventful outcomes 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> 
> ------------------------------ 
> 
> Message: 13 
> Date: Thu, 14 Feb 2008 06:53:19 -0500 
> From: "Ronald Gross" 
> Subject: Re: CT confirmation of healing spleen 
> To: 
> Message-ID: <47B3E55F.7FF1.00B9.0 at harthosp.org> 
> Content-Type: text/plain; charset=US-ASCII 
> 
> Sal, 
> This image has no blush - but I wonder about the rest of the scan. Based ONLY 
> on this image, would you have squirted this kid? 
> Ron 
> 
> >>> 2/14/2008 1:30 AM >>> 
> 
> In a message dated 2/12/2008 8:17:32 P.M. W. Europe Standard Time, 
> Rgross at harthosp.org writes: 
> 
> Hey Sal, are you out there? Have you seen this kind of defect on a healed 
> spleen? 
> 
> >>> "Ronald Simon" 2/12/2008 12:31 PM >>> 
> Yea, i know....... BUT, as you said, that was quite the crack to begin with. 
> Personally, i have never seen such a large remaining defect. That said, i 
> learn and see new stuff everyday. 
> ron 
> 
> 
> just catching up. 
> 
> we have seen patients who ended up healing two separate splenic segments do 
> very well, and our patients have some interesting "contact" sports to contend 
> with 
> 
> however i must remind that we do empiric angiography and will embolize 
> anyone with a angiographic blush. So our experience is kind of different. 
> 
> sal 
> 
> 
> 
> **************The year's hottest artists on the red carpet at the Grammy 
> Awards. Go to AOL Music. 
> (http://music.aol.com/grammys?NCID=aolcmp00300000002565) 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> 
> 
> ------------------------------ 
> 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> End of trauma-list Digest, Vol 56, Issue 15 
> ******************************************* 

------------------------------

Message: 5
Date: Thu, 14 Feb 2008 10:27:02 -0500
From: htaed_rd at 123mail.org
Subject: Re: 1:1 Blood Resuscitation, Round 2.
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <1203002822.28519.1236865951 at webmail.messagingengine.com>
Content-Type: text/plain; charset="ISO-8859-1"

We need to do research that will be large enough to produce enough
subjects in the various treatment arms that differences in outcome will
be clear.

As long as the research is small enough, or not well enough controlled,
that readers can look at the study and state that it is flawed, we will
be avoiding progress.

In 1989 in the cardiology community the question was which
antiarrhythmic, when given to patients who had had heart attacks, would
save the most lives (and make drug companies the most money).

All of the studies prior to that point had been on a surrogate end point
- which drug did a better job of eliminating PVCs.

It was taken for granted that, since patients with PVCs die more
frequently than those without PVCs, that eliminating PVCs saves lives.

The experts were in agreement on this theory.

The study was large enough to show survival differences and it was
allowed to go long enough to produce statistically significant numbers.

Too many studies are stopped early because the results are "too good to
justify withholding the study treatment from others," or vice versa.

How many of these treatments are found to be as beneficial/harmful in
follow up research?

How much of this is self delusion by the study designers?

The result of the CAST (Cardiac Arrhythmia Suppression Trial) was a
surprise to the cardiology world.

One of the drugs was leading to study participant deaths at 3 to 4 times
the rate of placebo.

The best that could be said about any of the drugs was that it did not
appear to be killing the patients at a greater rate than placebo.

All of these drugs are still used, just not very often.

Cardiologists no longer prescribe drugs to get rid of PVCs to everyone
who has had a heart attack.

Antiarrhythmia therapy has become much more conservative (part of that
is due to implantable defibrillators).

Had this study not been done, how long might it have taken before
someone realized this treatment was harmful.

Almost 20 years later, would this still be the focus of care following a
heart attack?

Diseased hearts have PVCs due to underlying disease.

Giving the patient a rhythm stabilizing drug does not change the disease
process, at least not for the better.

This study should have been an example to researchers everywhere.

In stead, it is viewed as an oddity specific to the cardiology
community.

It is not.

We need research that does an excellent job of controlling for as many
variables as possible.

Too much research contains discussions of why variable A is not worth
controlling for, even though it would have been relatively easy to
control for it.

We need to keep these flawed researchers from continuing to do fatally
flawed research.

How is it that experienced researchers, with doctorates in their fields,
continue to engage in research that should not receive passing marks
from a high school science teacher? 

The scientific method is one of the most important tools we have.

Its misuse kills.

Tim Noonan.

On Thu, 14 Feb 2008 06:03:48 -0800, "Sise, Mike MD"
<Sise.Mike at scrippshealth.org> said:
> So there is controversy over 1:1. How do we answer the question? Is a
> randomized trial justified or is it promising enough to just do it? On
> the one hand, we spent over 40 years using the intellectually attractive
> "balanced salt solution" lactated ringers without examining its impact.
> And blood transfusion therapy during the same interval may have been
> dictated by the technology that allowed fractionated blood banking - we
> abandoned whole blood. On the other hand, the results of 1:1 appear
> extremely promising. Pre-treatment Informed consent will be out of the
> question. Soooo, how about it Ken, Karim, Ron, Tim, all you
> trauma.org-istas.
>  
> Mike Sise
> San Diego
> 
> "Scripps Information Security" 
> ------------------------------------------------------------------------------
> This e-mail and any files transmitted with it may contain privileged and
> confidential information and are intended solely for the use of the
> individual or entity to which they are addressed. If you are not the
> intended recipient or the person responsible for delivering the e-mail to
> the intended recipient, you are hereby notified that any dissemination or
> copying of this e-mail or any of its attachment(s) is strictly
> prohibited. If you have received this e-mail in error, please immediately
> notify the sending individual or entity by e-mail and permanently delete
> the original e-mail and attachment(s) from your computer system. Thank
> you for your cooperation.
> 
> 
> ==============================================================================
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/

------------------------------

Message: 6
Date: Thu, 14 Feb 2008 10:37:01 EST
From: SJASMD at aol.com
Subject: Re: CT confirmation of healing spleen
To: trauma-list at trauma.org
Message-ID: <c70.25e9f43e.34e5ba1d at aol.com>
Content-Type: text/plain; charset="US-ASCII"

In a message dated 2/14/2008 6:53:50 A.M. Eastern Standard Time,  
Rgross at harthosp.org writes:

Sal,
This image has no blush - but I wonder about the rest of the  scan.   Based 
ONLY on this image, would you have squirted this  kid?
Ron

ron

have you ever treated conservatively someone without a CT blush who failed  
conservative management? 

Based on the CT, I would definitely done an arteriogram, probably  within an 
hour. I know that this is considered overkill but my sphincter doesn't  
tighten anymore. 

Negative angio, successful nonoperative therapy
positive angio, plus proximal coiling, successful nonoperative  therapy

This strategy gives virtually no failure. Only requires sufficient  stability 
to allow CT. Failure of nonoperative therapy should be a sentinel  event. 

**************The year's hottest artists on the red carpet at the Grammy 
Awards. Go to AOL Music.      
(http://music.aol.com/grammys?NCID=aolcmp00300000002565)

------------------------------

Message: 7
Date: Thu, 14 Feb 2008 12:04:49 -0500
From: "Ronald Gross" <Rgross at harthosp.org>
Subject: Re: 1:1 Blood Resuscitation, Round 2.
To: <trauma-list at trauma.org>
Message-ID: <47B42E61.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII

Let me be the first to say that I am going to continue to use 1:1:1 as it was presented in Spinella, Holcomb et al, and start to collect data to prove to Karim that this IS the proper way to go if we want to decrease morbidity and mortality in these audibly bleeding patients!  ;-)

>>> "Sise, Mike MD" <Sise.Mike at scrippshealth.org> 2/14/2008 9:03 AM >>>
So there is controversy over 1:1. How do we answer the question? Is a randomized trial justified or is it promising enough to just do it? On the one hand, we spent over 40 years using the intellectually attractive "balanced salt solution" lactated ringers without examining its impact. And blood transfusion therapy during the same interval may have been dictated by the technology that allowed fractionated blood banking - we abandoned whole blood. On the other hand, the results of 1:1 appear extremely promising. Pre-treatment Informed consent will be out of the question. Soooo, how about it Ken, Karim, Ron, Tim, all you trauma.org-istas.

Mike Sise
San Diego

"Scripps Information Security" 
------------------------------------------------------------------------------
This e-mail and any files transmitted with it may contain privileged and confidential information and are intended solely for the use of the individual or entity to which they are addressed. If you are not the intended recipient or the person responsible for delivering the e-mail to the intended recipient, you are hereby notified that any dissemination or copying of this e-mail or any of its attachment(s) is strictly prohibited. If you have received this e-mail in error, please immediately notify the sending individual or entity by e-mail and permanently delete the original e-mail and attachment(s) from your computer system. Thank you for your cooperation.

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------------------------------

Message: 8
Date: Thu, 14 Feb 2008 12:08:35 -0500
From: "Ronald Gross" <Rgross at harthosp.org>
Subject: Re: 1:1 Blood Resuscitation, Round 2.
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <47B42F43.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII

Tim,

Sorry to ask, but what exactly is/was your point?

Ron

>>> <htaed_rd at 123mail.org> 2/14/2008 10:27 AM >>>
We need to do research that will be large enough to produce enough
subjects in the various treatment arms that differences in outcome will
be clear.

As long as the research is small enough, or not well enough controlled,
that readers can look at the study and state that it is flawed, we will
be avoiding progress.

In 1989 in the cardiology community the question was which
antiarrhythmic, when given to patients who had had heart attacks, would
save the most lives (and make drug companies the most money).

All of the studies prior to that point had been on a surrogate end point
- which drug did a better job of eliminating PVCs.

It was taken for granted that, since patients with PVCs die more
frequently than those without PVCs, that eliminating PVCs saves lives.

The experts were in agreement on this theory.

The study was large enough to show survival differences and it was
allowed to go long enough to produce statistically significant numbers.

Too many studies are stopped early because the results are "too good to
justify withholding the study treatment from others," or vice versa.

How many of these treatments are found to be as beneficial/harmful in
follow up research?

How much of this is self delusion by the study designers?

The result of the CAST (Cardiac Arrhythmia Suppression Trial) was a
surprise to the cardiology world.

One of the drugs was leading to study participant deaths at 3 to 4 times
the rate of placebo.

The best that could be said about any of the drugs was that it did not
appear to be killing the patients at a greater rate than placebo.

All of these drugs are still used, just not very often.

Cardiologists no longer prescribe drugs to get rid of PVCs to everyone
who has had a heart attack.

Antiarrhythmia therapy has become much more conservative (part of that
is due to implantable defibrillators).

Had this study not been done, how long might it have taken before
someone realized this treatment was harmful.

Almost 20 years later, would this still be the focus of care following a
heart attack?

Diseased hearts have PVCs due to underlying disease.

Giving the patient a rhythm stabilizing drug does not change the disease
process, at least not for the better.

This study should have been an example to researchers everywhere.

In stead, it is viewed as an oddity specific to the cardiology
community.

It is not.

We need research that does an excellent job of controlling for as many
variables as possible.

Too much research contains discussions of why variable A is not worth
controlling for, even though it would have been relatively easy to
control for it.

We need to keep these flawed researchers from continuing to do fatally
flawed research.

How is it that experienced researchers, with doctorates in their fields,
continue to engage in research that should not receive passing marks
from a high school science teacher? 

The scientific method is one of the most important tools we have.

Its misuse kills.

Tim Noonan.

On Thu, 14 Feb 2008 06:03:48 -0800, "Sise, Mike MD"
<Sise.Mike at scrippshealth.org> said:
> So there is controversy over 1:1. How do we answer the question? Is a
> randomized trial justified or is it promising enough to just do it? On
> the one hand, we spent over 40 years using the intellectually attractive
> "balanced salt solution" lactated ringers without examining its impact.
> And blood transfusion therapy during the same interval may have been
> dictated by the technology that allowed fractionated blood banking - we
> abandoned whole blood. On the other hand, the results of 1:1 appear
> extremely promising. Pre-treatment Informed consent will be out of the
> question. Soooo, how about it Ken, Karim, Ron, Tim, all you
> trauma.org-istas.
>  
> Mike Sise
> San Diego
> 
> "Scripps Information Security" 
> ------------------------------------------------------------------------------
> This e-mail and any files transmitted with it may contain privileged and
> confidential information and are intended solely for the use of the
> individual or entity to which they are addressed. If you are not the
> intended recipient or the person responsible for delivering the e-mail to
> the intended recipient, you are hereby notified that any dissemination or
> copying of this e-mail or any of its attachment(s) is strictly
> prohibited. If you have received this e-mail in error, please immediately
> notify the sending individual or entity by e-mail and permanently delete
> the original e-mail and attachment(s) from your computer system. Thank
> you for your cooperation.
> 
> 
> ==============================================================================
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/ 
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
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------------------------------

Message: 9
Date: Thu, 14 Feb 2008 12:11:13 -0500
From: "Ronald Gross" <Rgross at harthosp.org>
Subject: Re: CT confirmation of healing spleen
To: <trauma-list at trauma.org>
Message-ID: <47B42FE1.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII

OH, THANK YOU, THANK YOU, Sal.
I would have had this kid in the angio suite PDQ (pretty damn quick) for angio/embo based solely on the exact point you raised -  "have you ever treated conservatively someone without a CT blush who failed conservative management".  I have the same tone that you do, and if I were afraid of any spleen failing conservative management, this would have to be one of those!

Ron

>>> <SJASMD at aol.com> 2/14/2008 10:37 AM >>>

In a message dated 2/14/2008 6:53:50 A.M. Eastern Standard Time,  
Rgross at harthosp.org writes:

Sal,
This image has no blush - but I wonder about the rest of the  scan.   Based 
ONLY on this image, would you have squirted this  kid?
Ron

ron

have you ever treated conservatively someone without a CT blush who failed  
conservative management? 

Based on the CT, I would definitely done an arteriogram, probably  within an 
hour. I know that this is considered overkill but my sphincter doesn't  
tighten anymore. 

Negative angio, successful nonoperative therapy
positive angio, plus proximal coiling, successful nonoperative  therapy

This strategy gives virtually no failure. Only requires sufficient  stability 
to allow CT. Failure of nonoperative therapy should be a sentinel  event. 

**************The year's hottest artists on the red carpet at the Grammy 
Awards. Go to AOL Music.      
(http://music.aol.com/grammys?NCID=aolcmp00300000002565)
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

------------------------------

Message: 10
Date: Thu, 14 Feb 2008 13:44:51 -0500
From: htaed_rd at 123mail.org
Subject: Re: 1:1 Blood Resuscitation, Round 2.
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <1203014691.4888.1236912927 at webmail.messagingengine.com>
Content-Type: text/plain; charset="ISO-8859-1"

On Thu, 14 Feb 2008 12:08:35 -0500, "Ronald Gross" <Rgross at harthosp.org>
said:
> Tim,
> 
> Sorry to ask, but what exactly is/was your point?

If Dr. Mattox was not just being polite when he wrote "YES, I agree.  
It will be a great session, and I don't really  know who will
will win.   It will all be in the  delivery," then the research
certainly needs to improve significantly. We have far too much that is
the result of persuasive researchers. In stead, we need persuasive
research, not charismatic people driving patient care decisions with
research that does not address what it claims to address. I am not
stating that there is any particular trauma study that this would
describe, but that if the delivery is the deciding factor, the research
is less than adequate.

Tim Noonan. 

> Ron
> 
> >>> <htaed_rd at 123mail.org> 2/14/2008 10:27 AM >>>
> We need to do research that will be large enough to produce enough
> subjects in the various treatment arms that differences in outcome will
> be clear.
> 
> As long as the research is small enough, or not well enough controlled,
> that readers can look at the study and state that it is flawed, we will
> be avoiding progress.
> 
> In 1989 in the cardiology community the question was which
> antiarrhythmic, when given to patients who had had heart attacks, would
> save the most lives (and make drug companies the most money).
> 
> All of the studies prior to that point had been on a surrogate end point
> - which drug did a better job of eliminating PVCs.
> 
> It was taken for granted that, since patients with PVCs die more
> frequently than those without PVCs, that eliminating PVCs saves lives.
> 
> The experts were in agreement on this theory.
> 
> The study was large enough to show survival differences and it was
> allowed to go long enough to produce statistically significant numbers.
> 
> Too many studies are stopped early because the results are "too good to
> justify withholding the study treatment from others," or vice versa.
> 
> How many of these treatments are found to be as beneficial/harmful in
> follow up research?
> 
> How much of this is self delusion by the study designers?
> 
> The result of the CAST (Cardiac Arrhythmia Suppression Trial) was a
> surprise to the cardiology world.
> 
> One of the drugs was leading to study participant deaths at 3 to 4 times
> the rate of placebo.
> 
> The best that could be said about any of the drugs was that it did not
> appear to be killing the patients at a greater rate than placebo.
> 
> All of these drugs are still used, just not very often.
> 
> Cardiologists no longer prescribe drugs to get rid of PVCs to everyone
> who has had a heart attack.
> 
> Antiarrhythmia therapy has become much more conservative (part of that
> is due to implantable defibrillators).
> 
> Had this study not been done, how long might it have taken before
> someone realized this treatment was harmful.
> 
> Almost 20 years later, would this still be the focus of care following a
> heart attack?
> 
> Diseased hearts have PVCs due to underlying disease.
> 
> Giving the patient a rhythm stabilizing drug does not change the disease
> process, at least not for the better.
> 
> This study should have been an example to researchers everywhere.
> 
> In stead, it is viewed as an oddity specific to the cardiology
> community.
> 
> It is not.
> 
> We need research that does an excellent job of controlling for as many
> variables as possible.
> 
> Too much research contains discussions of why variable A is not worth
> controlling for, even though it would have been relatively easy to
> control for it.
> 
> We need to keep these flawed researchers from continuing to do fatally
> flawed research.
> 
> How is it that experienced researchers, with doctorates in their fields,
> continue to engage in research that should not receive passing marks
> from a high school science teacher? 
> 
> The scientific method is one of the most important tools we have.
> 
> Its misuse kills.
> 
> Tim Noonan.
> 
> 
> On Thu, 14 Feb 2008 06:03:48 -0800, "Sise, Mike MD"
> <Sise.Mike at scrippshealth.org> said:
> > So there is controversy over 1:1. How do we answer the question? Is a
> > randomized trial justified or is it promising enough to just do it? On
> > the one hand, we spent over 40 years using the intellectually attractive
> > "balanced salt solution" lactated ringers without examining its impact.
> > And blood transfusion therapy during the same interval may have been
> > dictated by the technology that allowed fractionated blood banking - we
> > abandoned whole blood. On the other hand, the results of 1:1 appear
> > extremely promising. Pre-treatment Informed consent will be out of the
> > question. Soooo, how about it Ken, Karim, Ron, Tim, all you
> > trauma.org-istas.
> >  
> > Mike Sise
> > San Diego
> > 
> > "Scripps Information Security" 
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Message: 11
Date: Thu, 14 Feb 2008 15:19:19 -0500
From: "Ronald Gross" <Rgross at harthosp.org>
Subject: Re: 1:1 Blood Resuscitation, Round 2.
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <47B45BF7.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII

Gotcha.  On that I do agree.

Take care,
Ron

>>> <htaed_rd at 123mail.org> 2/14/2008 1:44 PM >>>
On Thu, 14 Feb 2008 12:08:35 -0500, "Ronald Gross" <Rgross at harthosp.org>
said:
> Tim,
> 
> Sorry to ask, but what exactly is/was your point?

If Dr. Mattox was not just being polite when he wrote "YES, I agree.  
It will be a great session, and I don't really  know who will
will win.   It will all be in the  delivery," then the research
certainly needs to improve significantly. We have far too much that is
the result of persuasive researchers. In stead, we need persuasive
research, not charismatic people driving patient care decisions with
research that does not address what it claims to address. I am not
stating that there is any particular trauma study that this would
describe, but that if the delivery is the deciding factor, the research
is less than adequate.

Tim Noonan. 

> Ron
> 
> >>> <htaed_rd at 123mail.org> 2/14/2008 10:27 AM >>>
> We need to do research that will be large enough to produce enough
> subjects in the various treatment arms that differences in outcome will
> be clear.
> 
> As long as the research is small enough, or not well enough controlled,
> that readers can look at the study and state that it is flawed, we will
> be avoiding progress.
> 
> In 1989 in the cardiology community the question was which
> antiarrhythmic, when given to patients who had had heart attacks, would
> save the most lives (and make drug companies the most money).
> 
> All of the studies prior to that point had been on a surrogate end point
> - which drug did a better job of eliminating PVCs.
> 
> It was taken for granted that, since patients with PVCs die more
> frequently than those without PVCs, that eliminating PVCs saves lives.
> 
> The experts were in agreement on this theory.
> 
> The study was large enough to show survival differences and it was
> allowed to go long enough to produce statistically significant numbers.
> 
> Too many studies are stopped early because the results are "too good to
> justify withholding the study treatment from others," or vice versa.
> 
> How many of these treatments are found to be as beneficial/harmful in
> follow up research?
> 
> How much of this is self delusion by the study designers?
> 
> The result of the CAST (Cardiac Arrhythmia Suppression Trial) was a
> surprise to the cardiology world.
> 
> One of the drugs was leading to study participant deaths at 3 to 4 times
> the rate of placebo.
> 
> The best that could be said about any of the drugs was that it did not
> appear to be killing the patients at a greater rate than placebo.
> 
> All of these drugs are still used, just not very often.
> 
> Cardiologists no longer prescribe drugs to get rid of PVCs to everyone
> who has had a heart attack.
> 
> Antiarrhythmia therapy has become much more conservative (part of that
> is due to implantable defibrillators).
> 
> Had this study not been done, how long might it have taken before
> someone realized this treatment was harmful.
> 
> Almost 20 years later, would this still be the focus of care following a
> heart attack?
> 
> Diseased hearts have PVCs due to underlying disease.
> 
> Giving the patient a rhythm stabilizing drug does not change the disease
> process, at least not for the better.
> 
> This study should have been an example to researchers everywhere.
> 
> In stead, it is viewed as an oddity specific to the cardiology
> community.
> 
> It is not.
> 
> We need research that does an excellent job of controlling for as many
> variables as possible.
> 
> Too much research contains discussions of why variable A is not worth
> controlling for, even though it would have been relatively easy to
> control for it.
> 
> We need to keep these flawed researchers from continuing to do fatally
> flawed research.
> 
> How is it that experienced researchers, with doctorates in their fields,
> continue to engage in research that should not receive passing marks
> from a high school science teacher? 
> 
> The scientific method is one of the most important tools we have.
> 
> Its misuse kills.
> 
> Tim Noonan.
> 
> 
> On Thu, 14 Feb 2008 06:03:48 -0800, "Sise, Mike MD"
> <Sise.Mike at scrippshealth.org> said:
> > So there is controversy over 1:1. How do we answer the question? Is a
> > randomized trial justified or is it promising enough to just do it? On
> > the one hand, we spent over 40 years using the intellectually attractive
> > "balanced salt solution" lactated ringers without examining its impact.
> > And blood transfusion therapy during the same interval may have been
> > dictated by the technology that allowed fractionated blood banking - we
> > abandoned whole blood. On the other hand, the results of 1:1 appear
> > extremely promising. Pre-treatment Informed consent will be out of the
> > question. Soooo, how about it Ken, Karim, Ron, Tim, all you
> > trauma.org-istas.
> >  
> > Mike Sise
> > San Diego
> > 
> > "Scripps Information Security" 
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> > 
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Message: 12
Date: Tue, 12 Feb 2008 11:49:18 -0500
From: "Bjorn, Pret" <pbjorn at emh.org>
Subject: RE: Who's doing 1:1 blood transfusions for shock?
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <9CCE32ECAAFDEB4DA01EC771B6AD951BFB2706 at VALIER.me.emh.org>
Content-Type: text/plain; charset="us-ascii"

For what it's worth, I've appended the most recent version of our
Massive Transfusion Protocol (finalizing as I type; still technically a
DRAFT).  It includes default conditions for dispensing plasma.  I'd be
obliged for your collective kindly critiquing...

Also have attached a couple of documents we stole from Baltimore in
consideration of building Factor VII into our process.  Interesting
reading.

While we're on the subject, my hospital is struggling with ubiquitous
chronic community anticoagulation (there's warfarin in the drinking
water, and more patients on clopidogrel than multivitamins), which
conspires against our rural elderly (geography is destiny -- especially
when your blood won't clot).  If anyone would like to share their
approaches, we're all ears.  Just got a new platelet function analyzer,
and we're itchin' to use it!

Pret Bjorn, RN
EMMC Trauma Program
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Sise, Mike MD
Sent: Tuesday, February 12, 2008 10:56 AM
To: trauma-list at trauma.org
Subject: Who's doing 1:1 blood transfusions for shock?

To all,

Who's doing 1:1 fresh frozen plasma to packed RBCs transfusions and
limiting crystalloid for resuscitation in hemorrhagic shock? If you've
adopted it - why? If not - why? Any and all comments requested.

Mike Sise
San Diego

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