So far, I'm seeing two potentially useful gaps in research that we can use to achieve the
objectives of this project (our goal is to advancing knowledge on the topic find gaps in existing
research as a basis for by recommending further research).
1. Lack of consensus on a specific relationship between platelet count (or other coags) and risk
of spinal hematoma (all other things being equal - procedure, equipment, technique, etc).
2. Lack of research on the relationship between bleeding risk and equipment,
specifically needle type used for the neuraxial procedure. So far, from the research I've gone
through, the huge difference in bleeding risk that appears to exist between spinal and epidural
is really simply a function of the type of needle more than difference in procedure. It seems
that the epidural needle tends to be larger because it's used to thread a catheter
From: Ruzich, Thomas (Barry Student)
Sent: Monday, June 2, 2014 3:01 PM
To: Milewski, Amy (Barry Student); Ramirez, Enrique (Barry Student); Willis, Jessica (Barry Student);
Morrissey, Daniel (Barry Student)
Cc: Dillon, Danielle (Barry Student)
Subject: RE: From our meeting
Hey Group,
I put together a rough draft outline. Feel free to manipulate, add, or tweak it. Once we have a
formal outline, we can start the body.
Tom
From: Milewski, Amy (Barry Student)
Sent: Monday, June 02, 2014 12:24 AM
To: Ramirez, Enrique (Barry Student); Willis, Jessica (Barry Student); Morrissey, Daniel (Barry Student)
Cc: Ruzich, Thomas (Barry Student); Dillon, Danielle (Barry Student)
Subject: RE: From our meeting
I found some great articles today. Based on those I was thinking I could cover either:
the risks (& signs/symptoms) of neuraxial hemorrhage or the role of pre-eclampsia and blood
pressure management guidelines related to HELLP syndrome and complication prevention.
Amy Milewski
amy.milewski@mymail.barry.edu
From: Ramirez, Enrique (Barry Student)
Sent: Sunday, June 01, 2014 8:10 AM
To: Willis, Jessica (Barry Student); Morrissey, Daniel (Barry Student)
Cc: Ruzich, Thomas (Barry Student); Milewski, Amy (Barry Student); Dillon, Danielle (Barry Student)
Subject: RE: From our meeting
Jessica,
The introduction sounds great, thanks for getting things rolling!
All 4 topics are important to discuss, all together should make a solid review paper.
I'll go ahead and do research on labs and diagnostics for bleeding risks. Everyone let me know
what you focus will be, if I run into something that your looking for I can then send it your way.
-Enrique
954-816-3844
From: Willis, Jessica (Barry Student)
Sent: Friday, May 30, 2014 4:37 PM
To: Morrissey, Daniel (Barry Student)
Cc: Ruzich, Thomas (Barry Student); Milewski, Amy (Barry Student); Ramirez, Enrique (Barry Student);
Dillon, Danielle (Barry Student)
Subject: Re: From our meeting
Dan
We picked this subject partly because we wanted to cover something we knew we would have
to understand and be tested on. Also because we’ve noticed this issue to come up a few times
during OB rotation. i.e. a patient comes in 37 week and is showing signs of HELLP syndrome so
her platelets are dropping. If the plts are at a level where its safe to insert the catheter, (maybe
it was inserted before her plt ever fell), the plts may continue to fall post op and removal of the
catheter later may pose a risk of hematoma which if unnoticed or not quickly addressed could
lead to paralysis. They may have to wait many days before the plts return to normal to safely
pull the cath. So they may just pull the catheter before the plts drop further. Or because they
need to do a stat c sec and plt are falling they may just do a spinal because the needle is much
smaller, but then you can’t redose. General anesthesia has the highest mortality rate for OB
patients. I recognized this week that as you said, there is a lot of older research that is pretty
well established and accepted. New research may be more challenging to come by. We are not
so much looking at comparison of epi/spinal as noted in the PICOT as we are looking to
determine, based the situation, on lab work, plt levels, plt function, coagulation studies, etc
what is the best strategy to implement regional anesthesia in order to avoid general anesthesia
while ensuring the safe practice. I have noticed that even if there is a coagulation risk they may
determine based on other plt fnx tests that an epidural or spinal can still be done. I hope this
HELLP s :)
Everyone,
Lets start splitting up the work. Here are some areas I think we may need to research:
1. Appropriate plt levels for insertions. How does this vary for epidural vs spinal, cath or no cath
2. What other lab studies are done to determine bleeding risk
3. If a catheter is placed and HELLP develops, plts fall, when do you pull it? what level do the
plts need to be, how long does it take for the plt to return to this level?
4. Maybe a discussion on: If bleeding does occur after insertion or cath removal, what happens,
signs symptoms
Please give input, do you think points need to be added, removed, and pick a topic you would
like to research and let us know what you will cover:) If it is okay I would like to continue
working on the intro and I can do a conclusion also. Our research will likely overlap but at least
this gives us a starting point.
Finally, we have six members and our group is messed up on the draft. She has not responded
to my email. I guess we can call her next week. Maybe she is on vacation?
Jessica
On May 30, 2014, at 10:19 AM, Morrissey, Daniel (Barry Student)
<daniel.morrissey@mymail.barry.edu> wrote:
Jessica,
Sorry for the late reply. I realized where you were coming from when I read it, so I didn't take it
that way at all and I appreciate your consideration in clarifying. If I was taking patho and
chemistry along with this course, I probably wouldn't be spending a lot of time on this course
and I wouldn't probably want to be getting lengthy emails on this project like the one I'm
sending you - but I'd rather err on the side of over communicating so I understand if you don't
have time to read or respond.
I'm not sure you guys have had a chance to come up with a plan for dividing responsibility on
the project? Also, I was hoping for some clarification on the topic. I probably only have a
superficial grasp on the topic compared with you guys but I did have a couple questions. The
comparison of interest is epidural versus spinal neuraxial anesthesia, the outcome of interest is
risk of hemorrhage, and the target population is HELLP patients.
It looks like earlier research has been done on this comparison of interest, but is only
referenced in later studies focusing on neuraxial anesthesia in HELLP patients, so it seems that
the previous research is generally accepted as applicable to HELLP patients as well. Are we
thinking that there are variables specific to HELLP patients significant enough to alter the
hematoma risk difference between spinal and epidural anesthesia? The previous research
showed such a significant risk difference between epidural and spinal that it's difficult to think
of anything that could impact the outcome.
I'd appreciate any clarification you can give on this
Thanks
Dan
386-453-6925
From: Willis, Jessica (Barry Student)
Sent: Tuesday, May 27, 2014 12:16 PM
To: Morrissey, Daniel (Barry Student)
Subject: Re: From our meeting
Hi Dan,
I was just looking at the e mail I sent you this weekend and realized it probably came across as
really rude. It was not my intension. We have the benefit of having been exposed to HELLP and
have all been tested on neuraxial anesthesia. So if anything is not clear feel free to just call or
email one of us so you don't have to waste a bunch of time doing extra reading when we can
quickly provide an explanation.
Jessica Willis
Sent from my iPhone
On May 24, 2014, at 6:31 AM, "Morrissey, Daniel (Barry Student)"
<daniel.morrissey@mymail.barry.edu> wrote:
Looks like there's a good amount of fairly recent research on the general topic, but just to
clarify - we're comparing the safety of epidural versus continuous spinal on HELLP pts regarding
risk of bleeding? If it's acceptable, I'll just start looking for research and compiling a list until we
have a specific plan for coordinating efforts.
Dan
386-453-6925
From: Milewski, Amy (Barry Student)
Sent: Friday, May 23, 2014 7:10 PM
To: Ramirez, Enrique (Barry Student); Ruzich, Thomas (Barry Student); Willis, Jessica (Barry Student);
Dillon, Danielle (Barry Student); dldillonster@gmail.com;Daniel.morrissey@mymail.barry.edu.;
Morrissey, Daniel (Barry Student)
Cc: Milewski, Amy (Barry Student)
Subject: FW: From our meeting
Hi everyone!
I want to welcome our new group members Dan & Danielle! Tom, Dr. Lee sent me an email as
well as you can see below. Danielle & Dan, please see a few emails below in the thread to see
the topic we chose today when we met. Over the next week or 2, we are going to all look for
appropriate articles to include. All articles must be from within the last years & peer-reviewed.
Happy Friday to all! : )
From: Lee, Rebecca M <RMLee@barry.edu>
Sent: Friday, May 23, 2014 3:20 PM
To: Milewski, Amy (Barry Student); Dillon, Danielle (Barry Student); 'dldillonster@gmail.com'
Subject: Headstart student joining your group
Hi Amy,
When you get your group members together, can you please share topic and members names
with Headstart student Danielle Dillon.
Her email is Danielle.dillon@mymail.barry.edu or dldillonster@gmail.com
I am copying her in this email as well so she will have your contact information to start
networking.
Thank you in advance.
Have a great weekend.
Rebecca Lee
From: Morrissey, Daniel (Barry Student)
Sent: Friday, May 23, 2014 7:42 PM
To: Ruzich, Thomas (Barry Student)
Subject: RE: Orlando group
Tom,
I'm going to be on the road for a few hours today, so I'll check my email when I'm back. I
typically get up around 3am for school stuff when I'm working - which is every Sun,Mon,Tues
7a-7p and I'm pretty good about checking email regularly and I can usually respond to text
messages anytime. I'll wait to hear from you about the project.
Dan 386-453-6925
From: Lee, Rebecca M <RMLee@barry.edu>
Sent: Friday, May 23, 2014 3:14 PM
To: Ruzich, Thomas (Barry Student); danmorrissey@cfl.rr.com; Morrissey, Daniel (Barry Student)
Subject: Orlando group
Hi Tom,
When you have your email group members, please be informed that your Headstart student will be
Daniel Morrissey. His email is
Daniel.morrissey@mymail.barry.edu. I am copying him in this email. Please share with him your topic
and team members.
Rebecca Lee
From: Milewski, Amy (Barry Student)
Sent: Friday, May 23, 2014 3:01 PM
To: Ramirez, Enrique (Barry Student); Ruzich, Thomas (Barry Student); Willis, Jessica (Barry Student)
Subject: From our meeting
Research Topic in the form of a PICOT:
o
o
o
o
o
P = Patient population of interest ( 1)HELLP pt
I = Intervention of interest (neuraxial ane)
C = Comparison of interest (spin/epid)
O = Outcome of interest (risk of hemorrhage & mgmt)
T = Time (24h to 7d?)
"Appropriate neuraxial management in parturient patient with HELLP
syndrome."
1. HELLP sx summary – stats/why we care/incidence rate
1. bleed risk one of our concerns for RA
2. epid. hematoma/bleed risks w. spin/epid b/w HELLP v. non-HELLP pts
3. Mgmt/Recommendation
1. When to insert (plat, coags?, TEG)
2. When to remove
Thank you very much.
Respectfully,
Amy Milewski
(312) 339-5307
amy.milewski@mymail.barry.edu