From: trauma-list-bounces@trauma.org on behalf of ecthompson
[ecthompson@msn.com]
Sent: 19 February 2004 12:27 PM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Changing behavior...
As a healthcare worker we all must do what we feel is in the best interest of
our patients. We can't deliver a therapy that we know or feel is harmful. This
is ethically wrong.
Here are some articles to help you feel better about NOT giving steroids.
*****ANNALS OF SURGERY*****
(REFERENCE 1 OF 5)
94029215
Galandiuk S, Raque G, Appel S, Polk HC
The two-edged sword of large-dose steroids for spinal cord trauma.
In: Ann Surg (1993 Oct) 218(4):419-25; discussion 425-7
ISSN: 0003-4932
OBJECTIVE: In 1990, large-dose steroid administration was advocated
in spine-injured patients to lessen neurologic deficits. The authors
undertook both prospective and retrospective studies to evaluate the
response of such profound pharmacologic intervention. SUMMARY
BACKGROUND DATA: Of all sources of nonfatal injury, spinal cord
trauma remains the most devastating in both cost and impact on the
quality of the patient's life. One study found that routine large-
dose steroid administration after injury lessened the extent of
neurologic injury. After uncommonly prompt and broad lay press
publicity, this practice was widely accepted. Biased by knowledge of
the known immunosuppressive effects of steroids, the authors
suspected that pneumonia was both more frequent and severe in steroid-
treated patients. METHODS: Thirty-two patients with cervical or upper
thoracic spinal injuries (C3-6, 20 patients; C6-7, 6 patients; and T1-
6, 6 patients) were studied at an urban level I trauma center from
January 1987 to February 1993. Complete spinal cord injury was
present in 22 of 32 patients; 14 patients received steroids
postinjury. There was no difference in mean age, cord level, age-
adjusted injury severity score, or the percent of injury severity
score caused by the spinal injury. RESULTS: The length of hospital
stay was longer in steroid-treated patients (S) than in nonsteroid
(NS) patients, that is, 44.4 days versus 27.7 days, respectively (p =
0.065). Seventy-nine per cent of S patients had pneumonia compared
with 50% of NS patients (p = 0.614). There was no statistical
difference in the episodes of pneumonia per patient between the two
groups (p > 0.05). Prospectively, the authors evaluated sequentially
several parameters known to be important in human immune responses to
bacterial challenges in nine S and five NS patients. In S patients,
both the per cent and density of monocyte class II antigen expression
and T-helper/suppressor cell ratios were lower than in NS patients.
However, S patients did have an initially higher, earlier boost in
some host defense parameters that rapidly declined, and their
subsequent response was both blunted and delayed. These differences
became even clearer when stratified according to cord level and
incomplete versus complete cord status. Not surprisingly, infected
patients, whether S or NS, had lower levels of monocyte antigen
expression, CR3, and helper/suppressor ratios. CONCLUSIONS: These
data do not permit a judgment to be made whether neurologic status
was improved by S administration. It is known that vital immune
responses were adversely affected, that pneumonia was somewhat more
prevalent, and that hospitalization was prolonged and costs therefore
increased by an average of $51,504 per admission. Further clinical
studies will be needed to determine to what extent these observations
offset the putative benefits of large-dose steroids in the treatment
of spinal trauma.
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Department of Surgery
Division of Neurosurgery
University of Louisville School of Medicine
Kentucky.
*****CURRENT OPINION IN NEUROLOGY*****
(REFERENCE 2 OF 5)
21579585
Short D
Is the role of steroids in acute spinal cord injury now resolved?
In: Curr Opin Neurol (2001 Dec) 14(6):759-63
ISSN: 1350-7540
Steroids have long been used in the context of acute spinal cord
injury but the evidence for doing so is limited. The second National
Acute Spinal Cord Injury Study trial had the potential to provide
such evidence for the first time, as this was a placebo controlled,
prospective, randomized trial. From the outset, however, some
clinicians found the methodology and consequently the results
unsatisfactory. This concern has been revisited within the evidence-
based framework of critical appraisal of the accumulation of clinical
studies. High-dose methylprednisolone cannot be justified as a
standard treatment in acute spinal cord injury within current medical
practice.
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Midlands Centre for Spinal Injuries
Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust
Oswestry
Shropshire SY10 7AG
UK. debbie.short@rjahoh-tr.wmids.nhs.uk
*****JOURNAL OF TRAUMA*****
(REFERENCE 3 OF 5)
99082943
Nesathurai S
Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3
trials.
In: J Trauma (1998 Dec) 45(6):1088-93
ISSN: 0022-5282
The National Acute Spinal Cord Injury Study (NASCIS) 2 and 3 trials
are often cited as evidence that high-dose methylprednisolone is an
efficacious intervention in the management of acute spinal cord
injury. Neither of these studies convincingly demonstrate the benefit
of steroids. There are concerns about the statistical analysis,
randomization, and clinical end points. Even if the putative gains
are statistically valid, the clinical benefits are questionable.
Furthermore, the benefits of this intervention may not warrant the
possible risks. This paper comments on these two clinical trials.
Comment in: J Trauma. 2000 Mar;48(3):558-61
Comment in: J Trauma. 2001 Aug;51(2):421-3
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Boston University School of Medicine and New England Regional Spinal Cord Center
Boston Medical Center
Massachusetts 02118-2393
USA.
(REFERENCE 4 OF 5)
95018411
Prendergast MR, Saxe JM, Ledgerwood AM, Lucas CE, Lucas WF
Massive steroids do not reduce the zone of injury after penetrating
spinal cord injury.
In: J Trauma (1994 Oct) 37(4):576-9; discussion 579-80
ISSN: 0022-5282
The National Acute Spinal Cord Injury Study II concluded in 1990 that
high-dose methylprednisolone (MP) improved neurologic recovery after
acute spinal cord injury (ASCI). We tested this conclusion by
analysis of 54 patients with ASCI; 25 patients were treated without
MP before 1990 whereas 29 patients were treated with MP after 1990.
Neurologic deficit was assessed regularly, in most cases daily. Motor
and sensory scores on admission, and best results at one-half week
(days 2 to 4), 1 week (days 6 to 10), 2 weeks (days 11 to 21), 1
month, and 2 months were noted for both groups. Motor assessment was
recorded in 22 muscle segments on a scale of 0 (complete deficit) to
5 (normal); the range, thus, was 0 to 110. The 23 patients with
closed injuries demonstrated no difference in improvement with or
without MP. In contrast, MP was associated with impaired improvement
in the patients with penetrating wounds; the 15 patients with no MP
therapy had an admission motor score of 49, which increased by 6.9 at
one-half week, whereas the 16 patients treated with MP had an
admission motor score of 48, which decreased by 0.3 at one-half week
(p = 0.03). The neural status seen by day 4 persisted throughout the
next 2 months. Changes in sensation paralleled the changes in motor
function. We conclude that MP therapy for penetrating ASCI may impair
recovery of neurologic function.
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Department of Surgery
Wayne State University
Detroit
MI 48201.
*****SPINE*****
(REFERENCE 5 OF 5)
21665377
Hurlbert RJ
The role of steroids in acute spinal cord injury: an evidence-based
analysis.
In: Spine (2001 Dec 15) 26(24 Suppl):S39-46
ISSN: 0362-2436
STUDY DESIGN: Literature review. OBJECTIVES: The purpose of this
article is to review the available literature and formulate evidence-
based recommendations for the use of methylprednisone in the setting
of acute spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: Since
the early 1990s, methylprednisolone has become widely prescribed for
the treatment of acute SCI. Arguably, it has become a standard of
care. METHODS: Through an electronic database search strategy and by
cross-reference with published literature, appropriate clinical
studies were identified. They were reviewed in chronologic order with
respect to study design, outcome measures, results, and conclusions.
RESULTS: Nine studies were identified that attempted to evaluate the
role of steroids in nonpenetrating (blunt) spinal cord injury. Five
of these were Class I clinical trials, and four were Class II
studies. All of the studies failed to demonstrate improvement because
of steroid administration in any of the a priori hypotheses testing.
Although post hoc analyses were interesting, they failed to
demonstrate consistent significant treatment effects. CONCLUSIONS:
From an evidence-based approach, methylprednisolone cannot be
recommended for routine use in acute nonpenetrating SCI. Prolonged
administration of high-dose steroids (48 hours) may be harmful to the
patient. Until more evidence is forthcoming, methylprednisolone
should be considered to have investigational (unproven) status only.
Comment in: Spine. 2001 Dec 15;26(24 Suppl):S55
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Department of Clinical Neurosciences
University of Calgary
Foothills Hospital
1403 29th Street NW
Calgary
Alberta T2N 2T9
Canada. jhurlber@ucalgary.ca
Questions?
E
Errington C. Thompson, MD
Trauma/Surgical Critical Care
Trinity Mother Frances
Tyler, Tx
ecthompson@tyler.net
Don't think you are
Know you are
- Morpheus (The Matrix)
-----Original Message-----
From: trauma-list-bounces@trauma.org [mailto:trauma-list-bounces@trauma.org] On
Behalf Of Sherry, Scott :LPH Trauma
Sent: Thursday, February 19, 2004 1:59 AM
To: trauma-list@trauma.org
Subject: Changing behavior...
Recent case of central cord syndrome, steroids given. I know the list's argument
and agree they dont have proven benefit and probably do more harm. But my
question is this... as we were discussing the fact that the above may be true it
was pointed out that steroid administration in spinal injury has become a
"standard of care" and not doing it has reporcussions as well (ie neglegence,
substandard care etc)
Is this true? ( I cant imagine it is). References
How does one change the behavior if it is true?
Thanks.
I will be away at a conference for a week and look forward to the flurry of
emails and lively discusion when I get home...
Scott...
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