Trauma Surgeons Gone Wild – PROPPR Trial

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Stefan T. -

I may have interpreted this wrong, but it is the final conclusion that mortality at 24 hours was better in the 1:1:1 group and no significant difference in long term mortality. This was seen as beneficial. The dichotomy between viewpoints on this conclusion, and conclusions on epinephrine in cardiac arrest trials where survival to admission is increased, but long term survival is unchanged is interesting. I have heard people say with epi that we are just changing the setting of the ultimate outcome-icu vs. ED. Is this the same with choice of blood products?

Ethan B. -

It's a important trial and it's wonderful to hear from our colleagues in other fields. But, sometimes expert opinion masquerades as evidence-based medicine. The two red flags for this that we hear all the time are appeals to 1) non-significant "trends," especially in post-hoc subgrounp analysis, and 2) cause-specific mortality. Dr. Inaba appeals to the latter result and suggests we base our practice on this finding. I think that we know the problems with this and should call attention to it, rather than condoning that conclusion.
Unless maybe we're talking about being slowly picked to death by ravens, the outcome that matters to patients is all-cause mortality. If the all-cause mortality is the same and the cause-specific mortality is different, that is an interesting finding, though. But, it means the intervention is either killing people a different way, or the coding of the cause of death is affected. All-cause mortality is a great end-point because it is quite objective. Cause-specific mortality on the other hand can be pretty subjective.
I think we need to be very strict about what we accept for conclusions from the data. As we have seen from mammography, expert opinion is a slippery slope towards inappropriate quality measures and wasted resources.

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