hot topics in icm - pincer course 25th sept 2015

Academic Department of Critical Care Queen Alexandra Hospital Portsmouth

Hot Topics in ICM

Steve Mathieu @stevemathieu75 @WessexICS

Consultant in Intensive Care Medicine Queen Alexandra Hospital, Portsmouth

15th September 2015

& some question spotting…

Examiners Report April/May 2014

http://www.ficm.ac.uk/sites/default/files/document-files/EXM-FFICM-Summary-ChairmanReport-April2014_0.pdf

Examiners Report Nov 2014

http://www.ficm.ac.uk/sites/default/files/Critical%20Eye%207%20-%20Winter%202015_0.pdf

‘some candidates appeared to consider that they should concentrate only on areas within their own experience rather than the breadth of the syllabus’

Examiners Report April 2015

http://www.ficm.ac.uk/sites/default/files/Critical%20Eye%208%20-%20Summer%202015%20FINAL%20WEBSITE2.pdf

“A doctor in training who is familiar with the syllabus and has done the necessary bookwork. They would clinically be at the level of a registrar who would be able to formulate a plan of care for a critically ill patient with appropriate consultant backup. Passing the exam is a requirement of progression to ST7 of the intensive care medicine training programme and the standard is set to reflect this”.

Hot Topics/Question spotting

• Examiners report • Syllabus • Review articles & key papers – JICS • Guidelines • Review FICM & ICS websites • Critical Eye • Other resources


Any dodgy ones?

Original Articles Reviews Case reports CAT reviews Others

August 2015 Psychological and neurocognitive consequences of critical illnessWeight calculationsScoring system for cirrhosis

NIV post oesophagecotmy. Safe?

Thyroid stormNAC

PARAMEDIC study (mechanical vs manual CPR)Damage control resuscitation

Prevention of VTEAnatomy of vessels relevant to central line placementNIV Defining deathStridor

May 2015 Tracheostomy careDepression following critical illnessConsultant cover and working practiceICU acquired weaknessPharmacokinetic considerations and dosing strategies of antibiotics

Strep toxic shock ProMISeCRISTAL Colloids vs crystalloids

Feeding patients with tracheostomiesAmitryptiline ODManaging acute central nervous system infections in the UK adult intensive care unit in the wake of UK encephalitis guidelines

Feb2015 Adult blunt chest traumaRRT in Scottish ICUsRehab after critical care

Troponin elevated in sepsis

DKA Monitoring-based antibiotic optimisation

VSE after IHCA

Rehab Improving qualityGPICSDoLS + DoLSEbolaTracheostomyAcute cardiomyopathy with amphetamine poisoning

October 2014 Minimising warm and cold ischaemic times liver transplantsDoLS +++Oral Feed and TracheostomyProphylactic IVC Filter

ECCO2R in NIVLimbic encephalitisEmphysematous pyelonephritisOndine’s Curse

Volume-Outcome Relationships for MV Adult Patients

Hyperglycaemic control on PICU

Evacuation of ICU due to a FireLetter about VAPHyperoxaemia in SAHElectrical Muscle Stimulation in ICU

July 2014 Echo in PEQuality (pressure ulcers)

DKAAcute mesenteric ischaemia

Epidural abscessJW GI haemorrhageMixed ODAcromegaly

Statin & VAPSEPSISPAMProtective ventilation in abdominal surgeryHeart rate control in septic shock

Delirium

April 2014 TracheostomyVAPImproving timeliness of time-critical transfers

HITHepatitis B & CSedationElectrical muscle stimulation in ICU (CIPN)

HD for dabigatran associated coagulopathyWernickesPatient with tetanus

TBIHope ICU (delirium)CSL or HESTTM

Prone ventilationCapnography

Jan 2014 COMET-UK (CO monitoring)Tracheostomy

Right heart failure Stabilisation and transport of critically ill child

ECG and traumaRhabdomyolysisPancreatitisMDMA toxicityHyperthyroidismPulmonary haemorrhage and AKI

TracMan AKIOrgan donationSurveillance for VAPPE supplement

Original Articles Reviews Case reports CAT reviews Others

October 2013

Echo NAVA ventilationPainBrainstem testing

Plasma exchange in HUSIntralipid in felodipine toxicityTracheostomy

Transfusion strategies for upper GI bleedProne TXA

Survey on rehab after critical illnessEcho in UKBlood transfusion in ICUBIS monitoringFaecal incontinence in ICU

July 2013 Noise level in ICU (delirium)

Serious Hazards of Transfusion (SHOT)Medical support for heart failurePCTNOCardiogenic shock

OTC deficiencyHyperkalaemia in HIV patient with ‘PCP’

ICP monitoringSedation

Gentamycin & vancomycinAncillary tests in diagnosis of brainstem testingLCPScoring systems for CAPAtrial Fibrillation in ICU

Guidelines


The Sepsis Studies


Neuro


http://www.wessexics.com/WICS_Guidelines/

The SAH section definitely worth a read for the exam

NCEPOD 2014: Tracheostomy• Documentation & consent

– Indications, type, inner tube, reasons for failed extubation/why no trial of extubation

• Different types of tubes • Rapidly available difficult airway

trolley • Training programmes in blocked/

displaced tubes • Capnography • Discharge of patients with

tracheostomy • MDT – physio & SALT


Capnography Airway equipment Back up planning Staffing Patient transfers Education/training Tracheostomy tube design Team working

Tracheostomy standards ICS• Indications for tracheostomy • Cautions and contraindications • Consent • Equipment • Ultrasound • Anaesthesia • Staffing • Types of tracheostomy tubes • Inner cannulae • Complication

– Early – Late – Airway emergencies

21

HFNC non inferior to facemask and NIV in ALI

ARDS - lots of trials

Neuro




ABLE Multicentre UK RBC transfusion (7d vs. 15-25d) NOAC

Transfusion triggers – TRICC, TRISS & Villaneuva, TITRe2 PROPPR: Plasma, Platelets & PRBC’s 1:1:1 vs. 1:1:2

Management of anaemia & RBC transfusion BCSH Guidelines 2012) Serious Hazards of Transfusion (SHOT) – JICS July 2013

Standards - quality• Staffing

– Consultant presence • 24/7 & within 30 minutes

– Consultant: patient 1:8 – 1:15; ICU resident/patient 1:8

– Designated CD – Ward rounds x2 daily – Training / FICM / Board Tutors – Nursing 1:1 (level 3); 1:2 (level 2) – MDT e.g. physio, pharmacy, dieticians

• Operational – Large ICUs divided into pods of 8-15 patients – Admit within 4 hrs of decision to admit – Avoid non-clinical transfers – Transfer to ward – clear and formalised – Out of hours transfers – Readmission within 48 hours bad – Assessment of rehab for each patient

• Equipment – Training

• Data Collection – ICNARC – Risk register


Quality Indicators

SMR Scoring Systems

MCA & DoLSDoLS • 3 cases in 2014


MUST READ….

The landmark papers in Critical Care


NAP 4 - 2011• All NHS hospitals for 1 year ’08-’09 • 184 reports

133 anaesthesia 36 ICU 15 ED

• Inclusion criteria death, brain damage emergency surgical airway unanticipated ICU admission

– Prolongation ICU stay


Summary of NAP 425% of major airway events in a hospital occur in ICU or the

ED

46% of ICU events and 53% of ED events occurred out of hours

50% of ICU events were due to tracheostomy related events

50% events in ICU and 27% events in ED resulted in death

61% events in ICU resulted in death or severe neurological harm


Recommendations Capnography Airway equipment Back up planning Staffing Patient transfers Education/training Tracheostomy tube design Team working


TracMan - 2013

•Early tracheostomy (by d 4) or late (>10/7)

– 455 patients – Mortality the same 31% – LOS the same 13 d – Complications slightly higher in late group 6% vs. 5%

Young et al. JAMA 2013 May 22;309(20):2121-9


ARDS - Incidence

• 1 yr prospective observational study; 255 patients

• Incidence 7.2/100,000/year (? US 75/100,000)

• Despite use of lung protective ventilation overall ICU mortality >40%


ARDS - lots of trials

OSCAR• 795 patients with moderate -

severe ARDS (<26.7kPa / 200mmHg)

• CMV vs. HFOV (MV <7 days) • No difference in

– 30/7 mortality (41%) – Duration antimicrobial agents (2/3

chest sepsis) – Vasoactive support duration – ICU LOS – Hospital LOS


OSCILLATE• 548 patients with moderate - severe

ARDS • HFOV vs low Vt/High PEEP CV (MV <

3d) • Trial stopped early as harm with HFOV • HFOV

– Hospital mortality 47% vs 35% – More sedation – More NMBA’s – More vasopressors


PROSEVA• 466 patients with severe ARDS • Prone position vs supine position • Prone position was associated

with – Improved mortality

• 28 day: 16% vs 33% • 90 day: 24% vs 41%

– Less cardiac arrests – No difference in

complications


PROSEVA


HARP 2 - 2014

• 540 patients ARDS; 40 UK ICUs • ARDSnet +/- statin for 28 days (80mg od simvastatin) • Primary outcome

– No difference in ventilator free days at 28d

• Secondary outcome – No difference in SOFA, oxygenation – Elevated CK or ALT/AST > in statin

group


Statins in ARDS

• Multicentre, RCT • Rosuvastatin vs. placebo in ARDS • Statin may modulate inflammatory response • 745 patients (trial stopped early because of

futility) • Primary outcome:

• 60d mortality: 28.5% vs. 24.9% (statin vs. placebo) • Ventilator free days: 15.1 vs. 15.1


Statin & VAP• 300 patients with suspected VAP

(CPIS ≥ 5) • Simvastatin 60mg vs placebo • No difference in

– 28d survival – ICU or hospital mortality – Duration MV – Delta SOFA

• Increased mortality in statin naieve


BALTI - 2012

• 162 patients; 46 UK ICU’s • ARDS & MV

- salbutamol 15mcg/kg/hr or placebo - Treatment for up to 7 d

• Mortality greater in those given salbutamol 34% vs 23% at 28d


Steroids in ARDS

• 9 studies (4 RCT’s & 5 cohort) • 648 patients • Trend to reduced mortality but only ss when result pooled • Trials vary ++ 1.Dose 2.Initiation of treatment 3.Course length 4.Not all studies report adverse events


Nitric oxide – just say No• Potent pulmonary vasodilator which when inhaled =

selective vasodilation in well ventilated lung units • Improved V/Q mismatch and PVR & PAP • Also anti-inflammatory effects • Systematic review of 12 trials with 1200 patients =

improved oxygenation d1, no improvement in mortality

• ⇧AKI and methaemaglobinaemia ⇧intracranial bleeding in children

Afshari Cochrane review 2007 - adults Barrington Cochrane review 2010 – children Afshari – systematic review 2011


Magnesium in asthma

• 1200 patients 2008-2012 • Neb vs. IV Mg vs. placebo • No role for neb Mg • Limited role at best for IV

Mg • Not life threatening

asthma

Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial Goodacre et al Lancet 2013 Vol 1 (4) 293-300


VAP


What is VAP?

What are the common organisms (early

vs. late?

Scoring systems e.g. CPIS, HELICS

What antibiotics would you use?

How can you reduce incidence

Open Access!#FOAMcc

50

HFNC non inferior to facemask and NIV in ALI

FLORALI

• 12 French ICU’s; 310 patients • ‘ALI’ • NRB vs HFNC vs NIV • Primary outcome: Proportion of patients who required

endotracheal intubation within 28 days after randomisation:

• High-Flow oxygen: 40 patients (38%) • Non-invasive ventilation: 55 patients (50%) • Standard oxygen: 44 patients (47%) • p = 0.18


PREOXYFLOW

• 6 French ICUs. 119 patients • Acute hypoxaemia • Primary outcome: Lowest SpO2 during the

endotracheal intubation (ETI) procedure • ETI = the beginning of laryngoscopy to

patient connection to the mechanical ventilator

• HFNC 91.5 [80-96] vs HFFM 89.5% [81–95] p = 0.44.

• HFNC without discontinuation during an apnoeic period, was not any more effective than using a high FiO2 facemask at 15 l/min for preventing desaturation during RSI


CO Monitoring – COMET-UK• Survey to all UK ICUs • Respondents

– Majority used CO monitoring • Oesophageal doppler 57% • LiDCO 43% • PiCCO 42%


How does doppler work? Thermodilution?

Pulse contour analysis ?

OPTIMISE• RCT, multicentre, 17 UK ICUs • 734 patients • > 50y undergoing GI surgery with one or more ‘high risk’ risk factors • Algorithm-directed care dictating colloid and dopexamine

administration using vs. clinician directed care without use of CO monitoring

• Primary outcome: composite of 30d mortality and mod/major complications

– Intervention: 36.6% – Control arm: 43.4%

• No SS difference in secondary outcomes – POMS, infectious complications, critical care free days at 30d, mortality

at 30d and 180d, hospital LOS


IVOIRE Study

• Randomised, open study • 18 ICU’s in France, Belgium and

Netherlands 2005-2010 • 140 pts with septic shock & AKI • HVHF 70mls/kg/hr v 35mls/kg/hr • Slow recruitment • No difference in mortality = 40%

28/7 • HVHF not recommended


TTM• 950 unconscious adults; 36 ICU’s • 33°C (n=473) with 36°C (n=466) • No difference in

– All cause mortality 33°C (50%) with 36°C (48%) – poor neurological function

at 180 days 33°C (54%) with 36°C (52%)


Cognitive function post TTM• 652 cardiac arrest survivors from TTM • Survival until 180 days 52% - invited to follow up - about half had psychometric testing - compared with a control group

(STEMI but no cardiac arrest) • About 50% had cognitive impairment • 33 vs. 36 vs. control group similar

• Attention & mental speed more affected in cardiac arrest patients

• Memory & executive functioning similar


Pre-hospital hypothermia• Prehospital cooling vs. standard care • 2L of cold normal saline once ROSC • 1,359 OOHCA patients • Cooling effective (reduced temp) • No difference

– Survival to hospital discharge • VF 63% vs 64% • nonVF 19% vs 16%

– Good neurological recovery • VF 57% vs 62% • nonVF 14% vs 13%


IABP – SHOCK II• 600 patients with cardiogenic shock

secondary to AMI • IABP vs no IABP • All received early revascularisation

and best medical therapy • No difference

– 30/7 mortality (40%) – ICU LOS, catecholamine, bleeding

• Lancet 2013 Sept – 12/12 results = no difference in mortality or reinfarction rate


VSE in cardiac arrest• 268 patients in hospital cardiac arrest • Vasopressin(20IU/CPR cycle) +

epinephrine (1mg/CPR cycle) + methylprednisilone (40mg) vs placebo + epinephrine (1mg/CPR cycle)

• VSE group – ROSC at 20 mins higher 84% vs 66% – Improved survival to hospital discharge with

CPC 1 or 2 – Improved haemodynamics & cvSpO2 – Less organ dysfunction

• and


Therapeutic Hypothermia after OOH CA in ChildrenIn children suffering an out-of-hospital cardiac arrest, does hypothermia (33)

compared to normothermia increase survival with a good neurobehavioural outcome?

38 sites in US & Canada; 260 patients

There was no statistically significant difference in survival to 12 months with good neurobehavioural outcome (age-corrected standard score of 70 or higher on the Vineland Adaptive Behaviour Scale 2nd ed. [VABS-II])


Therapeutic Hypothermia in Deceased Organ Donors and Kidney-Graft Function

• 394 donors with BSD • Mild hypothermia (34-35) vs

normothermia • Primary outcome: Delayed graft function

(the recipient's requirement for dialysis during the 1st week post-transplantation) - significantly lower in hypothermia group

• 28.2% vs 39.2%, P=0.008


Monitor: Protocolised fluid therapy in brain-dead donors

• US • BSD 508 • Protocolised LiDCO vs routine • Primary outcome: Number of organs transplanted per donor – no

difference


CHEER• Refractory cardiac arrest treated

with mechanical CPR, hypothermia, ECMO and early reperfusion

• 26 patients (11 OHCA; 15 IHCA) • Primary outcome

– Survival with good neurological recovery (CPC 1-2) 14/26 (54%)

• Secondary outcomes – ROSC achieved in 25/26 (92%) of patients – Survival to hospital discharge 14/26 (54%)



The oxygenator in veno-venous ECMO

Study type Year pub

N (ECMO)

N (non

ECMO)

% H1N1

ECMO mortality

Non-ECMO mortality

p

RCT 2009 90 90 0 37% 50% 0.07

RCT 1994 21 19 0 67% 58% 0.8

RCT 1979 48 42 0 90% 92% 0.84

Cohort 2006 32 118 0 47% 29% 0.06

Cohort 2000 62 183 0 45% 39% NS

Cohort 1997 49 73 0 45% 11% <0.001

Case series

2009 68 133 100% 23% 13% 0.06

Case series

2011 69 11 100% 27.5% ?52% ***

ECMO for H1N1• 2009-2010 • 80 patients referred for

ECMO • 69 received ECMO • 22 of these died (27.5%) • Matching cohort = 52% • For patients with H1N1

related ARDS, mortality reduced with ECMO


Passive Leg Raise


• Meta-analysis • 16 trials inc PEITHO, MAPPETT,

MOPETT, TOPCOT • Thrombolysis + anticoagulation

vs. anticoagulation alone • All cause mortality less in

thrombolysis group but major bleeding & ICH higher


SEPSIS

The Sepsis Studies


ARISE• Randomised, controlled,

multicentre, • 51 hospitals 1,600 patients with

septic shock • EGDT vs. Usual Care • No difference in:

– All cause mortality at 90d (18%) – ICU & Hospital LOS


ProCESS• RCT 31 ICUs in US • 03/2008 – 05/2013 • 1351 patients with septic shock • 3 groups

– EGDT – Protocol based standard therapy – Usual care – No difference in 60 d mortality between

groups


ProMISe• RCT 56 ICUs in UK • 02/2011 – 07/2014 • 1260 patients with septic shock • EGDT vs Usual care

– All cause mortality at 90 days in EGDT group vs. usual care group

– 29.5% vs. 29.2% p=0.9


Ferrer: Empiric antibiotics in sepsis

• Retrospective observational cohort study • 165 ICUs – Europe, US & S America • Jan 2005- Feb 2010 • 18,000 patients with septic shock • Delay in antibiotics administration over first 6 hours after

identification of SS or septic shock -> increased mortality • < 1 hr 24.6%; 1-2h 25.9% > 6h 33%


SEPSISPAM• RCT, multicentre, 29 French ICUs • March 2010 – Dec 2011 • Septic shock • Target MAP 80-85 vs. 65-70 • No difference in

– 28 day mortality (high MAP 36.6% vs. 34%) • New AF 6.7% in higher MAP group vs. 2.8% P=0.02 • In chronic hypertension group, worsening creatinine and need for RRT

was lower in higher MAP group


PROWESS SHOCK• Randomised, controlled,

multicentre, parallel group study • 1,697 patients with septic shock • No difference in

– 28 day mortality (APC 26.4% vs 24.2%)

– 90 day mortality (34.1% vs 32.7%) • No subgroup effect seen in protein C

deficient group • Serious bleeding n = 10 APC vs 8

placebo


B blockers in septic shock• Open label, single unit • Septic shock + HR ≥ 95 + NADR • 77 patients – esmolol infusion (HR

80-94) vs 77 patients standard treatment

• Esmolol group – 28d Mortality 50% vs 81% in placebo – Improved SV index, LVSWI, lactate – Less NADR requirement – Less fluid requirement


Esmolol in refractory VF• Single centre, non randomised • 25 patients with refractory (>3 defib

attempts) VF or pulseless VT • Esmolol vs. placebo • Primary outcome

– Survival with good neurological recovery – 50% esmolol vs 11% control group – No difference in rates of ROSC or survival

to hospital discharge


Steroids in Sepsis


The evidence…..let’s give it


8 trials published before ’89 - No mortality benefit (some worse) - Decreased time for shock resolution - More secondary infections - Higher doses and for shorter periods

19 ICU’s 300 patients - 50mg hydrocortisone + fludrocorisone vs. placebo by 8hrs of onset of septic shock. - ‘Non responders’ (adrenal suppression) better ICU (53% vs. 63%) and hospital mortality (61% vs. 72%). - Increase secondary bacterial infections - NNT = 7 (Annane JAMA 2002)

The evidence…..perhaps don’t give


CORTICUS

- 52 ICU’s, 499 patients

- 50mg hydrocortisone QDS vs. placebo 6/7 - 28/7 mortality no different between groups and subset of non- responders

Quicker shock resolution, catecholamine sparing, more secondary infections Sprung et al. NEJM 2008: 358; 111-24

- Etomidate used in 1/5th of patients - Only 35% power to detect a 20% mortality reduction - High variability between laboratories in cortisol assays

Hang on….


Post hoc analysis of patients in VASST

Review of patients with noradrenaline (293) and steroids and vasopressin (295) and steroids 28 day mortality difference 44.7% versus 35.9% (p=0.03) ? Increased responsiveness to catecholamines ? Increased vasopressin levels ? Decreased inflammation Russell J, et al, Interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock, Crit Care Med 2009 Vol. 37, 811-8

VANISH – second arm includes steroids. Eagerly await results

VASST


- RCT 778 pts with septic shock

- Noradrenaline vs. Norad & Vaso (0.03 units/min)

- No mortality benefit

- Higher doses associated with ischaemia

“Possible use if other vasopressors failed”

Less severe shock associated with reduced mortality when vasopressin used

Russell et al. NEJM 2008: 358: 877-87

VANISH


Vasopressin & corticosteroids in Septic Shock. A Pilot Study – Gordon A, 2014 Hydrocortisone - vasopressin sparing - reduced duration vasopressin - reduced dose vasopressin - no effect on vasopressin levels

ABLE• RCT 64 ICUs in Canada & Europe • 2510 patients administered RBC

transfusion up to seven days post ICU-admission & anticipated length of MV of at least 48 hours

• "fresh" RBC's (stored for 8 days or less) compared with standard issue RBCs (stored 2-42 days)

• Primary outcome: – 90 day mortality – 448 patients (37%) vs. 430 patients

(35%) (Absolute Risk Difference 1.7%; 95% CI -2.1-5.5)


TITRe2• RCT 17 cardiac ICUs in UK • In adults undergoing cardiac surgery,

does a restrictive transfusion strategy (Hb > 75 g/l) compared to a liberal transfusion strategy (Hb > 90 g/l) lead to fewer infections and ischaemic events within 3 months?

• No difference


TRISS• 32 general ICUs in Scandinavia • 998 patients with septic shock & Hb <9 • Transfusion threshold <7 vs. <9 • Excluded patients with ACS • Primary outcome:

– No difference in death at 90 days • Secondary outcomes: No difference in

• Vasoactive drugs • Ventilation • RRT • % of days alive & out of hospital • Ischaemic events


Acute UGI Bleed• Randomised, parallel group study • 921 pts with severe upper GI bleeding • Compared restrictive (Hb <7g/dL) vs liberal

transfusion strategy (Hb<9g/dL) • Restrictive strategy associated with

– Reduced number of pts receiving transfusion (15% vs 51%)

– Increased probability survival (HR 0.55) – Less rebleeding (10% vs 16%) – Less adverse events (40% vs 48%)


PROPPR

• RCT in 12 N. American Level 1 trauma centres • 680 patients • Transfusion of plasma:plts:PRBCs • 1:1:1 vs. 1:1:2 • Primary outcome:

- 24 hour and 30d mortality no different • Secondary outcomes: No difference

Time of haemostasis; Any of 23 pre-defined complications; Hospital, ventilator & ICU free days • Post- hoc analysis:

- Death by exasanguination in 1st 24 hrs much less in 1:1:1 group


PROPPR


TXACRASH - 2 Lancet 2010

• tranexamic acid in reducing transfusion requirements and death from significant haemorrhage following injury

• 20,000 patients

• Risk of haemorrhage reduced by 0.8% • No reduction in transfusion usage • Only 50% received blood and average only 3 (? ‘significant haemorrhage’)

CRASH - 2 subanalysis Lancet 2011 • Mortality directly related to haemorrhage Tranexamic acid only effective if within first 3 hours. Beyond

this time mortality increases


TXACRASH – 2 Does TXA reduce the risk of

intracranial bleeding in patients with TBI? BMJ 2011

• 250 of the 20,000 patients eligible. • Brain haemorrhage growth 5mm vs. 8mm (TXA vs. placebo) • Not SS • No mention of extent of extracranial injuries in either group

making mortality comparisons difficult • Not well matched as there were more pts with SAH (61% vs

43%) • No increase is focal cerebral ischaemia • Conclusion “it is probable that benefits of tranexamic acid

outweigh risks’


Trauma Haemorrhage

1. Coagulation monitoring and measures to support coagulation should be implemented early

2. Damage control surgery 3. Physiological targets, suggested use & dosing of

fluids, blood products and TXA 4. Patients on antiplatelet agents and/or oral

anticoagulants require special attention 5. Mutlidisciplinary approach & evidence based

protocols adapted to local circumstances need to be developed and implemented


Fluids• Don’t give too much • Don’t give too little • Make sure you give the right

amount • Starches bad…very bad Association of HES administration with mortality and AKI

in critically ill patients requiring volume resuscitation. Meta-analysis. JAMA 2013 vol 309 (7)

• Albumin back in? SAFE subgroup analysis 1200 pts with severe sepsis - 28/7

mortality lower in albumin group (30% vs. 35% OR 0.87) Finfer S et al 2011 Intensive Care Med 37:86–96 Delayney metaanalysis. Role of albumin as a

resuscitation fluid for patients with sepsis. 17 studies, 1977 patients. Crit Care Med 2011

Albios Study – Gattinoni (video ion ESICM website)


“lets talk about fluid responsiveness”

NO!

ESICM statement on colloids

1. Recommend not to use HES with mw ≥ 200kDa in patients with severe sepsis or risk of AKI

2. Suggest avoid 6% HES or gelatin in these groups 3. Recommend not to use colloids in patients with head

injury and not to administer gelatins and HES in orhan donors

4. Suggest avoid hyperoncotic solutions for fluid resuscitation


ALBIOS• RCT, 100 ICUs in Italy • Aug 2008 – Feb 2012 • 1818 patients with severe sepsis • 300mls 20% HAS daily to maintain serum albumin at 30g/dl + CSL vs.

CSL • Primary outcome: mortality at 28d

– HAS + CSL: 31.8% – CSL: 32%

• Secondary outcomes: 90 d mortality – No difference


6S Study• 804 ICU pts with severe sepsis • Compared fluid resuscitation

– 130/0.4 hydroxyethyl starch (tetraspan) vs Ringer's acetate

• HES associated with – Increased 90 day mortality 51% vs 43% – Increased RRT requirement 22% vs 16% – Trend for increased bleeding 10% vs 6%

-


CHEST Study• 7000 ICU pts • Fluid resuscitation with 6% HES

130/0.4 (Voluven) or 0.9% saline • No differences in

– Mortality (HES 18% vs 17%) – LOS – ICU / Hospital

• HES associated with increased – RRT (7% vs 5.8%; RR 1.21) – Pruritus / Rash / Hepatic failure

-


CRISTAL Study• 2857 sequential ICU patients 2003-2012 57

ICU’s • Colloids vs CSL for all fluid interventions

other than maintenance • Colloids

– Reduced mortality at 28d & 90d (25% vs 27% & 30% vs 34%) – More days alive without MV – More days alive without vasopressors – Less RRT

-


Gastrointestinal

Need a nice summary?


Open Access!#FOAMcc

CALORIES• Open, multicentre, RCT • 2400 patients in 33 ICUs in UK • PN vs. EN within 36 hours for 5/7 • Primary outcome:

– All cause mortality 33.1% (PN) vs. 34% (EN)

• Secondary outcome: – Vomiting more in EN – No difference on other 16 outcomes including

‘serious’ hypoglycaemia

– NB daily calorific targets achieved in <40% in both groups


The SuDDICU studySDD

12 meta-analyses of 28 RCT’s. 10 show reduced pneumonia rate; 6 show morality benefit

• Why have clinicians avoided implementing it in UK?

• What are the barriers?

• What further evidence is required before full scale clinical implementation


VITdAL-ICU• RCT, Single Centre with 5 ICUs in

Austria, 475 patients • Vit D or placebo • Primary outcome:

– Hospital LOS no different

• Secondary outcome. No difference: – ICU LOS – ICU-, 28d- , hospital- & 6 month- mortality

• Subgroup analysis – If severe vit D def and given Vit D3 -> improvement

in 28d- hospital- and 6 month- mortality


Systematic review: CCM 2010 In those patients

receiving enteral nutrition, stress ulcer prophylaxis may not be required and may actually increase VAP


H2R antagonists vs PPI

• Cohort Study of 35,000 pts

• MV > 24 hours and either H2R antagonist or PPI

• H2R antagonist group had – Less GI haemorrhage 2.1

vs 5.9%

– Pneumonia 27% vs 39%

– C.Diff 2.2% vs 3.8%


Hepatology

• ALD Alcohol related illness costs NHS £1.7 billion/year

Systematic review of 21 articles

Overall ICU mortality 40-50%

Mackle study only one to provide data on GI haemorrhage - mortality 48%, 62%, 67%,68% for unit, hospital, 6/12 and one yr - if get out of hospital most will survive

Organ support - 3 papers (ventilation, vasoactive drugs, RRT)

Mackle - - if MV and vasoactive drugs hospital mortality 86%

- If MV, vasoactive drugs and RRT > 90%

- If just MV 31%

Saliba RRT 90%

Rye 100% mortality if require RRT


STOPAH• RCT, 65 UK Hospitals • 1103 patients with alcoholic hepatitis • Primary outcome: mortality at 28 days was not

statistically different between any individual group – p-value for drug interaction was 0.41

• Prednisolone + placebo: 14.3% • Pentoxifylline + placebo: 19.4% • Prednisolone + pentoxifylline: 13.5% • Placebo: 16.7%

• Secondary outcome. No difference: – ICU LOS – ICU-, 28d- , hospital- & 6 month- mortality

• Subgroup analysis – If severe vit D def and given Vit D3 -> improvement in 28d- hospital-

and 6 month- mortality


Intraabdominal pressures

http://www.wsacs.org/

http://www.xigris.com/

Neuro




DESTINY II• RCT 13 hospitals in Germany • MCA infarct with NIHHS > 14 • Decompressive craniotomy vs standard ICU treatment • Primary outcome: score of 0-4 on Modified Rankin Scale

at 6 months • 20/49 in hemicraniectomy group vs. 10/63 in control

group • Bias-corrected, adjusted for the sequential nature of the

trial • 38% vs. 18%, OR 2.91 (95% C.I. 1.06-7.49, P=0.04) • Early hemicraniectomy significantly increased probability

of survival in patients >60 years of age with malignant MCA infarction, but most survivors had substantial disability


Neuro-ICU

ICP Monitoring• Multicentre RCT of 324

patients Bolivia and Ecuador

• Intraparenchymal ICP monitoring vs. clinical & imaging

• No difference in mortality or neuropsycholoigcal status at 6/12


A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury Randall M. Chesnut et al N Engl J Med 2012; 367:2471-2481

CATIS• 4,071 patients • Within 48 hrs ischaemic stroke • nonthrombolysed and ↑BP • Hypertension therapy vs no BP Rx • BP control effective • No difference

– death and major disability • 14 days / hospital discharge • 3 months


INTERACT 2

• 2,839 pts with early spontaneous intracerebral haemorrhage & ↑SBP

• Compared SBP <140 mmHg vs <180 • Aggressive BP control associated

with – Trend for less adverse events

(p=0.06) – Lower modified Rankin scores

• No difference in mortality


Magnesium for aneurysmal SAH (MASH-2): a randomised placebo-controlled trial Mees S et al. 2012 The Lancet. Vol 380 9834:44-49

• 8 ICU’s in Europe and S America • 1204 patients • The question: does Mg reduce poor

outcome by reducing vasospasm and delayed cerebral ischaemia (DCI)

• Magnesium 64mmol/day for 20/7 or placebo

• Primary outcome of poor outcomes as defined by score 4-5 on modified Rankin Scale at 3/12, or death

• NO DIFFERENCEAcademic Department of Critical Care

Queen Alexandra Hospital Portsmouth

Delirium

HOPE ICU• 142 patients with delirium • CAM-ICU assessment • Double blinded • Haloperidol vs. placebo • No change in duration of

delirium in critically ill patients • Haloperidol should be reserved

for short term management on acute agitation

Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial Valeirie Page. The Lancet Respiratory Medicine, Volume 1, Issue 7, Pages 515 - 523, September 2013


http://www.thelancet.com/journals/lanres/issue/vol1no7/PIIS2213-2600(13)X7010-9

Treating Delirium


101 MV patients RCT haloperidol vs. ziprasidone vs placebo 21/7 study period No difference in any of the groups!

The beginning; Kress NEJM 2000 Reduction in LOS

Girard Lancet 2008 Decreased ICU stay, time on ventilator and mortality

Strom Lancet 2010 Reduction in LOS and ventilator days No sedation group - boluses of morphine, well established in institution, more agitated delerium in no sedation group

Jacob JAMA 2012 PRODEX/MIDEX No better than midaz or propofol at maintaining light to mod sedation and more adverse effects. Increased patient interactions. Less vent days than midazolam

Ryker JAMA 2009 Reduction in ventilator days and delirium

Mehta 2013 For MV patients managed with protocolised sedation, the additon of daily sedation interruption did not reduce duration MV or ICU LOS

Don’t forget the simple things….


• Small RCT 136 patients • Used NEECHAM score • Delirium (20%) similar

but less mild confusion with ear plugs and good night sleep <50% vs. 25%

Guidelines for managing delirium


Functional disability 5 years after ARDS

109 survivors from ’98 - ’01 Interview, PFT’s, 6 min walk test, resting & exercise oximetry, chest imaging, QOL survey PFT’s normalish BUT 6 min walk test 76% predicted, physical/psychological problems


Microbiology

• 96 ICU’s • Data from 60,000 admissions ’09-’11 • Invasive fungal disease defined as BC

or sample from normally sterile site showing yeast/mould cells in a microbiological or histopathological report

• 383 (0.6%) were admitted with or developed IFD

• Conclusion: Incidence of IFD in non-neutropenic,

critically ill patients is low


4 steps to keep up with the literature after the exam


Sign up to criticalcarereviews.com

Check out emlitofnote.com, The Bottom Line & LITFL, ScanCrit & icmcasesummaries

Get a twitter account and follow #FOAMcc & #FOAMed http://www.wessexics.com/Wessex_ICM_Blog/files/5af570b612a8f22d6841f96179a2fc92-16.html

Podcasts – emcrit, RAGE, St.Emlyns, CRIT-IQ, PHARM, JICScast, FOAMcast, Critical Care Practitioner

http://www.wessexics.com/Wessex_ICM_Blog/files/5af570b612a8f22d6841f96179a2fc92-16.html


Best of Luck!

@stevemathieu75

wessexics.com portsmouthicu.com

http://www.wessexics.com

http://portsmouthicu.com

hot topics in icm - pincer course 25th sept 2015

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