Critical care reviews is a one day meeting in Belfast by Rob Mac Sweeney and the Northern Ireland Intensive Care Society. Adrian Wong and Jamie Strachan attended and have put together these notes for oxicm. Rob is going to put all the talks online over the next few weeks.
The Great Debate: RCTs are Killing Critical Care
Jean-Louis Vincent (@jlvincen): Damn Right!
-Fluid, BP, Hb, feeding all have been RCTed to show no benefit.
-Chest compression has never been RCTed and yet we still use and continue to investigate around its “fringes” e.g. LUCAS, continuous vs interrupted.
-Its the process of care NOT the actual RCTs that have advanced ICM.
-In conclusion, JLV advocates personalized and precision treatment plans
Luciano Gattinoni (@gattinon): You’re Having a Laugh?
The logic of RCTs and scientific reasoning
– It is not the RCTs but the interpretation and implementation of their findings that is the problem.
– Are we (all) too quick to throw away treatments after RCT? ECMO was discarded for 30 years after 1970 says @gattinon
– Problems with RCTs – premise and external validity. Not asking the right question – Wrong study=wrong result
JLV and Gattinoni both say – we are asking the WRONG questions.
Paul Young (@DogICUma): Saline or Plasmalyte? Is SPLiT the Solution?
Great discussion on this trial – well covered online in other places:
New data from Young was presented at this meeting however:
But this a non-significant result and was from a post hoc analysis of a non predefined subgroup, as Simon Carley pointed out from the twittersphere:
What it did do is help Dr Young and his colleagues with their next project- the PLUS trial: PlasmaLyte versus Saline trial – 40 sites, 8800 pos ? the definitive trial comparing plasmalyte and saline.
John Holcomb: How to Resuscitate PROPPRly
Again well covered elsewhere but a great run through today from John:
– plasma is a drug with thousands of proteins in it
– Holcomb explains survival bias: Did they live because they got the whole blood or did they live long enough to get the whole blood?
– PROMMTT data: “transfusion was random across centres”
– KM Curves in PROPPR already started separating within 3 hours
– Median time to haemorrhagic death in trauma 2.5hrs. It is products we give before this time that hold importance
– No point of care coagulation test is fast enough to keep up in active bleeding.
Tim Walsh (@Ed_TimWalsh): Is Old the new Young? The ABLE Trial
The conclusion? – Fresh red cells do not appear to be superior to standard issue red cells in critically ill adult patients.
Tim Walsh made the great point that so-called negative randomised control trials can reassure us we are doing no harm.