Salt water mastery

A BLOG BY DR JUSTIN MANDEVILLE () FOR OXICM

Wet, full, soggy, overloaded, oedematous. Dry, dehydrated, hypovolaemic, a fire hazard. Euvolaemic, replete, just right. The jargon of fluid status is commonly used, and abused on the ICU.

A 70 year old, with a several day prodrome of anorexia, diarrhoea, vomiting (more latterly blood-stained) arrives hypoxic, obtunded, with mottled peripheries, too much lactate and too little BP. We give some oxygen, some antibiotics to cover whichever horrendococcus is suspected, and some fluid. But how much fluid?

Now look at this diagram:

Screen Shot 2014-10-23 at 23.15.28

Is this an oversimplification? Almost certainly but it illustrates a point. With our patient we need to ask: do we want blood volume improved, do we want to rehydrate, or do we want to edge up the Frank-Starling hill?

Resuscitating sepsis

Our super-sick man will be dehydrated, likely hypovolaemic and will almost certainly be fluid responsive.

Recent evidence

ARISE patients received on average 1-3 litres prior to enrolment, 1-3 further litres over the next 6 hours and 1-7 litres over the next 66 hours with a small (and surely clinically insignificant) difference between the groups.

For ProCESS the numbers were very similar. Without the documented output/losses the fluid balance differences can’t be assessed but may turn up in some post-hoc introspection.

So everyone gets a few litres in 6 hours. These studies were both ‘non-positive’ – maybe the end-points for fluid resuscitation in sepsis don’t matter, within traditional doses and timing. Maybe we shouldn’t bolus at all. Maybe we shouldn’t give extra fluid at all. Just get somewhere near euvolaemia, rehydrate and maintain. Paul Marik enjoys showing us the flaws in the formative work on fluid in sepsis, but whether we’re ready to entertain trying out ‘dry resuscitation’ is debatable.

After 6 hours

Beyond the 6 hour package our patient is unlikely to be hypovolaemic. Beyond 6 hours we are very short on evidence-based guidance. Optimizing volume to optimise cardiac output is traditionally the next task. His CVP, PAWP, IVC dimension, LV end-diastolic area, corrected flow time, stroke volume and a number of other measurements all may have some theoretical value, but in actuality are worthless. Predicting fluid responsiveness is not about assessing frank hypovolaemia, for which some of these markers may be of value.

If you want to see how stable a system is, then give it a nudge. Bolus some fluid, or if your keen to avoid an unnecessary bolus then provoke the circulation with a breath (SVV, PPV, VTI variation) or a reversible 2-legs-worth bolus (passive leg raise). An alternative approach, although less applicable to our situation, you could take some fluid away and assess response.

Screen Shot 2014-10-23 at 23.13.17

These dynamic markers predict short term response to fluid. They make no promise about what the cardiac output will be in half an hour, and they make no promise about what the blood pressure will do. They tell you that cardiac output will improve, not that you need it or that it will benefit the patient in the short or long term.

Cut to day 2

Our man by this stage has some sort of ‘LipiccODM rapido™’ device which says his cardiac index is 2.9. TTE shows a capable LV without clear signs of septic cardiomyopathy but mild diastolic impairment. His lactate is 1.0. Noradrenaline is running at 0.2 mcg/kg/min. His urine output might be at or just above the magical 0.5ml/kg/hr but you know he’s taken a bit of a renal hit.

You find yourself mid-way through prescribing a bag of Hartmann’s because you absent-mindedly agreed with a comment “there’s a swing on that A-line, fill him up”.

Why increase his cardiac output. He might be fluid responsive but why does his cardiac output need to be max’d out. It’s at this point you should look ahead to the rest of his stay. Every water molecule and every salt molecule in that bag of fluid you’ve just prescribed needs to be got rid of somehow in the near future. If you enjoy creating a marsh-mallow man and watching him struggle with oedematous lungs, chest wall, abdominal viscera through the rest of their slow wean, then go right ahead.

Admittedly we’re short of a good blood volume monitor but knowing when your markers of fluid responsive are flawed is a good start. A swinging arterial line is normal in a patient breathing patient. And ‘swing’ does not reliably mean a high SVV or PPV.

Screen Shot 2014-10-23 at 23.15.13

Fluid removal

At some point our patient will tolerate fluid removal, or he’ll do it himself once kidney/endocrine/circulatory stars are aligned. No one knows how to manage this phase best but it’s becoming clear that following the theoretical yellow line below will get our man off the unit quicker, potentially in a healthier state, than following the red line.

How and when you achieve this is almost completely evidence free territory. ADQI again have some suggestions regarding targeted fluid removal:

Fluid balance target:

  • Depends on your impression of tolerance (stable dialysis can have litres taken off over a few hours)
  • A common approach is to try 500ml in 12 hours, then increase.

Clinical endpoints:

  • Better oxygenation
  • Less oedema

Safety endpoints:

  • Perfusion safety endpoints – falling BP, SVV > 25% if ventilated, rising noradrenaline requirement, lactate, or ScvO2.
  • Renal endpoints – creatinine or urea rise 10-20%, sodium rise >4 mmol.

Our man needed some help from vitamin F but tolerated over a litre negative balance per day from the third day with a significant decrease in FiO2 after the first 500ml. Extubation was possible on day 4 and renal function was near baseline by day 8 by which time he was back on the medical ward. 

Summary

So it’s no longer about being a ‘wet’ or ‘dry’ unit but being wet and dry in all the right places. Fluid is a drug that both saves lives and slows recovery. The finer points of administration and removal are yet to be elucidated but signals are already in the literature regarding the shaping of a patient’s dynamic fluid balance

P.S. Echocardiography is uniquely suited to assessing all these stages fluid assessment using quantitative and qualitative evaluation. But that’s another story.

  1. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564–75.
  2. Vincent J-L, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006 Feb;34(2):344–53.
  3. Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less is more. Chest. 2008 Jan;133(1):252–63.
  4. Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care. 2008;12(3):R74.
  5. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int. 2009 Aug;76(4):422–7.
  6. Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009 Jul;136(1):102–9.
  7. Bagshaw SM, Gibney RTN, McAlister FA, Bellomo R. The SPARK Study: a phase II randomized blinded controlled trial of the effect of furosemide in critically ill patients with early acute kidney injury. Trials. 2010;11:50.
  8. Boyd JH, Forbes J, Nakada T, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011 Feb;39(2):259–65.
  9. Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD, National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol. 2011 May;6(5):966–73
  10. Heung M, Wolfgram DF, Kommareddi M, Hu Y, Song PX, Ojo AO. Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury. Nephrol Dial Transplant. 2012 Mar;27(3):956–61.
  11. Teixeira C, Garzotto F, Piccinni P, Brienza N, Iannuzzi M, Gramaticopolo S, et al. Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care. 2013;17(1):R14.
  12. Schmidt M, Bailey M, Kelly J, Hodgson C, Cooper DJ, Scheinkestel C, et al. Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation. Intensive Care Med. 2014 Sep;40(9):1256–66.
JUSTIN IS AN ANAESTHETIC AND ICU CONSULTANT IN BUCKINGHAMSHIRE HOSPITALS, FICM TUTOR AND ECHO GURU AND HAS CREATED A GREAT FOAMCC SITE WITH A COMBINATION OF CRITICAL CARE GUIDELINES, EVIDENCE AND WISDOM; IE INTENSIVE CARE MEDICINE WORTH KNOWING! www.icmwk.com

 

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Part of the ProCESS

A BLOG BY DR olusegun olusanya () FOR OXICM
The following article contains minor spoilers for the Star Wars franchise

EPISODE IV: A NEW HOPE

A long time ago, in a galaxy far, far away

The late 1990s seem like a dark time for critically ill patients with sepsis. 28 day mortality approached 50%, with demonstrable delays in time to receive critical interventions such as antibiotics and fluids. Despite increased awareness, new definitions to help, and cool devices and ideas to maximise- and even supramaximise- oxygen delivery, mortality had not changed from severe sepsis and septic shock in nearly 40 years.

Enter Emmanuel Rivers, MD and Early Goal Directed Therapy.

You refer to the prophecy of the one who will bring balance to the force.
You believe it is this…

His team, from Detroit, Michigan, postulated that treating these severely ill patients early and aggressively, aiming to maximize certain resuscitation end points (CVP, MAP, urine output, central venous oxygen saturation, and haematocrit) within 6 hours with continuous monitoring and liberal use of fluids, blood, and vasopressors to achieve the targets.

The results were astounding- a reduction in in-hospital mortality from 46.5% to 30%. (15% ARR reduction, NNT 6). Published in the New England Journal of Medicine in 2001, this landmark paper transformed sepsis care around the world. So much so, that the 2008 Surviving Sepsis guidelines used the Detroit protocol essentially verbatim.

However, dark times were to come. Critics pointed out the rapid adoption of a single-centre unblended RCT with significants risk of bias. Undisclosed conflicts of interest were discovered. And, despite multiple attempts, no one was able to replicate the impressive results of Rivers’ trial (except for this one study from China).

Begun, the clone wars now has

The ProCESS study is the latest published attempt to verify the effects of EGDT. Conducted across 31 hospitals in the USA between 2007 and 2013, 1351 patients were enrolled in a 3 arm trial comparing EGDT as per Rivers’ protocol, a “protocolised” arm using less aggressive targets, and a “usual care arm”.

Mortality rates at 90 days were 21% EGDT, 18% “protocolised” and 19% “usual care”. The difference was not found to be statistically significant.

YOU WERE THE CHOSEN ONE!

Looking in closer at the trial, it’s difficult to see any major flaws. There was tight adherence to the protocols in all groups. The patients were similar to the ones in Detroit (APACHE scores etc).

It could be argued that there wasn’t enough difference between the groups. Each of them were resuscitated to some targets within 6 hours and had early antibiotics (indeed- fluid balance was quite similar between groups at 6 hours and 72 hours, except blood and inotropes which were higher in the Rivers group). It could also be argued that there was a “Hawthorne effect” of being in the trial, and that it may be underpowered to detect small mortality benefits.

The trial also shows some amazing stuff- the mortality from severe sepsis has been reduced in these American units by nearly 25% in the last 13 years. They’re doing similarly well down under, too.

No, I am your father…search your feelings, you know this to be true…
NOOOOOOOOO!!

It would seem that despite the controversy, EGDT ended up improving sepsis care throughout the USA by promoting early recognition and aggressive treatment. Dr Rivers did bring balance to the Force after all- perhaps not the way he initially intended.

There is still good in him…I can feel it.

So what does this mean for us ICM trainees in the UK? Based on fairly recent data, our severe sepsis mortality is hovering around 30% (as is most of Europe)… it would seem that there is room for improvement.

Use the Force, Luke…

I see a number of things we can do:

  1.       Help to answer the question locally. The UK Protocolised management in Sepsis (ProMISE) trial is currently recruiting, and is our own version of ProCESS. Help recruit and spread the word! (If you’re down under, the ARISE study is your local equivalent)
  2.       Improve local sepsis care. Give early antibiotics and fluids (use the sepsis six if you’re not already). Help out with audit and research- ask your local ED and ICU consultants how you can help.
  3.       Join the larger conversation. Read the paper, the editorial, and the excellent online commentaries (Like this one http://academiclifeinem.com/process-study-identify-sepsis-early-treat-aggressively/) . Discuss it at your local journal club. Get online and blog about it. Join Twitter and Google + and continue debating how we can further improve sepsis care. Listen to podcasts- Scott Weingart of emcrit.org has interviewed Derek Angus  (one of the key players in the study) -listen to it here http://emcrit.org/podcasts/process-trial/

Should we change practice based on this paper? I think that’s more for your local teams to decide. It would certainly seem that oximetric CVCs and optimising haematocrit doesn’t offer much over simpler targets (lactate clearance and MAP).

I suspect that many teams would like to see the results of ProMISE before making any big decisions. Interestingly, the plan is to combine the results of ProCESS, ARISE and ProMISE into a “supertrial” and do lots of clever analysis. The saga of EGDT is far from over…

You’re all clear kid! Now let’s blow this thing and go home!

REFERENCES

  1.       Friedman G, Silva E, Vincent JL. Has the mortality of septic shock changed with time. Crit Care Med 1998 Dec; 26(12): 2078-86  (http://www.ncbi.nlm.nih.gov/pubmed/9875924 )
  2.       Rivers E, Nguyen B, et al. Early Goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001 Nov 8; 345(19): 1386-77  (http://www.ncbi.nlm.nih.gov/pubmed/11794169)
  3.       Dellinger RP et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008 Jan; 36(1): 296-327 (http://www.ncbi.nlm.nih.gov/pubmed/18158437 )
  4.       Early Goal-Directed Therapy Collaborative Group of Zheijang Province. The effect of early goal directed therapy on treatment of critical patients with severe sepsis/septic shock: A multi-center prospective randomized control study. Zhonggue Wei Zhong Bing Ji Jiu Yi Xue 2010 Jun; 22(6): 331-4  (http://www.ncbi.nlm.nih.gov/pubmed/20594464 )- article in Chinese
  5.       The ProCESS investigators. A randomised trial of protocol-based care for Early Septic Shock. NEJM 2014 Mar 18. (Epub ahead of print) (http://www.ncbi.nlm.nih.gov/pubmed/24635773 )
  6.       Kaukonen KM et al. Mortality related to severe sepsis and Septic Shock among critically ill patients in Australia and New Zealand, 2000-2012. JAMA 2014 March 18 (online first). (https://jama.jamanetwork.com/article.aspx?articleid=1850096 )

USEFUL TWITTER LINKS

@theARISEstudy (twitter feed of Anthony Delaney, key investigator. He’s also a fountain of EGDT knowledge and will answer lots of questions related to ProCESS, ProMISE and ARISE!)

FURTHER LISTENING

Great podcast from 2012 by Anthony Holley on goal-directed therapy here http://intensivecarenetwork.com/index.php/icn-activities/icn-podcasts/247-goal-directed-therapy-by-anthony-holley-with-presentation

star-wars-stormtroopers-hospital_0Segun is an anaesthetic and ICU registrar in the Oxford deanery, Coeditor of JICScast, prolific twitterer and firm believer in / contributor to #FOAMed

How to pass the FFICM

A Blog by Dr MJ Slabbert ()for OXICM
no mean feet
Passing the FFICM: no mean feet
The only source of knowledge is experience. – Albert Einstein

…. well, lets just say – Einstein didn’t have a smartphone, Wi-Fi or the internet.

Being an “old school” trainee, I am a BIG supporter of this statement by Einstein. There truly is no substitute for experience.  Good and bad experiences – you can learn something from each type.  However we now live in an “IT” era where information is available at your fingertips.  Mobile technology has brought libraries, journals, studies, research, training videos, discussions and blogs with ease to the ward round.  This has changed the way we acquire knowledge, learn, change practice, share information, debate and prepare for exams.

Preparing for a different fellowship exam a few years ago I had 21 textbooks scattered all over my bedroom floor.  Then last year for the FFICM I had my laptop and the internet – with only a hand full of textbooks in sight.

So, for this, my first blog, I thought I’d share some strategies as well as online and electronic sources of “knowledge” and blogs that I found useful when I prepared for my FFICM exam a year ago – which I passed by the way!

In time, we are hoping to add the Oxford Deanery Intensive Care Medicine blog to this list of invaluable online resources.

Here goes…

Experience

It is still holds true that nothing beats experience.  I relied heavily on the experience I gained working in an excellent Intensive Care Unit to pass my exam.  My logic was that if they taught me the correct things and gave me the opportunity to gain the appropriate amount of experience, then supplementing this with a bit of reading should help me easily pass the exam.  And it did.  It is super important to get experience in a unit where there is a culture of teaching, learning, questioning, training and researching.  Seek out these opportunities.  Think big!  There are opportunities to do interdeanery secondments or go oversees and get a breath of experience and work with some incredible teachers.  This is the best way to acquire knowledge; at the coal face.

Printed resources

Ah, there are few things as comforting as a good book – even if it is a textbook.

There are numerous books covering the aspects of the FICM curriculum.  To date, as far as I am aware there is no one comprehensive textbook purely for this exam.  I used a few textbooks in my exam preparation.  These complemented each other.  A few of them are mentioned here and are available to purchase (google them).  The list below is not comprehensive and I have no conflict of interests to declare.

Textbook: MCQ

Multiple Choice Questions in Intensive Care Medicine Steve Benington, Peter Nightingale, Maire Shelly

– Written for the EDIC part 1 exam, but useful in MCQ practice for the FFICM

FRCA: MCQs for the Final FRCA: Saunders Self Assessment Series, 1e (FRCA Study Guides) Karen Henderson

-Strictly not an ICM textbook, but has lots of ICM relevant MCQs

Anaesthesia and Intensive Care A to Z: An Encyclopaedia of Principles and Practice Steven M Yentis

– A good book to for quick access facts. Useful in MCQs

Textbook: General reference

Oxford Desk Reference: Critical Care Carl Waldmann

-Quite comprehensive for its size. Good to get a general overview of most ICM topics

Oh’s Intensive Care Manual, 6e Andrew Bersten

– Just have it and read it – start early.

Oxford Handbook of Critical Care (Oxford Medical Handbooks) Mervyn Singer

– A small textbook and a bit of a taster but by itself not comprehensive enough for exam preparation

Critical Care Secrets, 5e Polly E Parsons

– One of my favourite textbooks, purely because of how it is written in question/answer format.  A really nice textbook to practice for likely viva questions.

Online resources

http://pact.esicm.org/index.php?ipTested=1

– The European Society of Intensive Care Medicine Patient-Centred Acute Care training resource is fantastic and available to all ESICM members.  It is also possible to get group / institutional access.  These training modules are very comprehensive and it takes quite a bit of time to go through each one.  They are regularly updated.  At the end of each module there is a number of MCQs relating to the topic.  There are good practice questions for the exam.

https://www.crit-iq.com/index.php/home

– This was one of my two main sources of knowledge while doing my Advanced (Step 2) ICM training and studying for the FFICM.  Although an Australian ICM site, it is jam packed with resources.  The website has recently added a specific FICM resource to the site.  The only downside is to have access to this fantastic resource you will need to become a member (or convince your institution to get institutional membership).

http://www.criticalcarereviews.com

– Excellent resource for keeping up to date with the latest research.

http://www.intensivecarenetwork.com

– Another Australian website, but excellent clinical resources for the Australian intensive care medicine exam. Also has some interesting podcasts

http://www.wellingtonicu.com/Education/Resources/

– For balance, a Kiwi site. Also full of exam resources from their side of the globe.

http://ccforum.com

– with Jean-Louis Vincent, Erasme University Hospital as the author this is a must read reference to stay in touch with the latest trends and reviews.

Blogs

http://lifeinthefastlane.com

– Essential online medical resources and reviews. Useful links for medical education, clinical medicine and health related online search.

http://www.sccmblogs.org

– Useful snippets of the latest research and controversies in critical care.

Apps

These are some of the apps on my smart phone that I used (a lot) for quick revision and to debate things with colleagues (young and old) on ward rounds.

ICU Trials

– An excellent app with summaries of all the landmark studies. Great for debating decisions on ward rounds.

ICU Pearls

ICU Notes

Critical Care

FOAMEd and twitter

 FOAMEd = Free Open Access Medical Education

This is the future of medical educations. There is no stopping this flood of information, discussion and knowledge sharing. It is international, real time and educational. Inspired by clinicians across the world and free.

By following #FOAMed on twitter you have access to a fountain of information for all things critical care.

If you are not on twitter yet, don’t get left behind in this knowledge revolution!

Well, that’s it for this blog. Hopefully (if I get asked back) the next blog will be based around a case and an educational topic.

Till then…

MJ IS AN ICU&ANAESTHETIC REGISTRAR AND PREHOSPITAL CARE DOCTOR IN OXFORD WHO (AMONGST MANY ACHIEVEMENTS) RECENTLY STARRED IN THE BBC2 MEDICAL SCIENCE DOCUMENTARY “An Hour to Save Your Life “

A landmark paper?

A blog by Dr James Day () for OXICM
simple
simple

I found this open access article doing the rounds on twitter. It was something that I had thought about too through my training:

Residents learning ultrasound-guided catheterization are not sufficiently skilled to use landmarks. Maizel J, Guyomarc H L, Henon P, Modeliar SS, de Cagny B, Choukroun G, Slama M. Crit Care. 2014 Feb 23;18(1):R36. [Epub ahead of print]

Pubmed link Open access link

Background

Current guidelines date back from 2002, issued by NICE. These have been reviewed, with no changes, in 2005 and 2010. Their guidance advises:

“Two-dimensional (2-D) imaging ultrasound guidance is recommended as the preferred method for insertion of central venous catheters (CVC’s) into the internal jugular vein (IJV) in adults and children in elective situations.”

“The use of two-dimensional (2-D) imaging ultrasound guidance should be considered in most clinical circumstances where CVC insertion is necessary either electively or in an emergency situation” 

The Committee also considered that although 2-D ultrasound imaging guidance in CVC placement may eventually become the routine method for placing CVC’s, the landmark method would remain important in some circumstances, such as emergency situations, when ultrasound equipment and/or expertise might not be immediately available. Consequently, the Committee thought it important that operators maintain their ability to use the landmark method and that the method continues to be taught alongside the 2-D-ultrasound-guided technique.

Study synopsis

It is a French study that looked at the ability of junior doctors to perform central venous catheters (CVC) via the traditional landmark technique. For the first 3 months they placed CVCs via ultrasound. In the next three months they were allowed to use the landmark technique. Initially there was a reduction in the success rate and an increase in the complication rate compared to using ultrasound. After 10 landmark CVCs placements the success rate and complication were at parity with the ultrasound technique.

They have a number of key messages:

•          The real-time ultrasound-guided technique is the recommended procedure for central vein catheterization. However, in emergency situations ultrasound machine may be unavailable.

•          To ensure that physicians are adequately skilled in all situations, they must be able to perform catheter placement without ultrasound.

•          Training in the ultrasound-guided technique provides the resident with certain, but insufficient skills for catheter placement by the landmark technique.

•          A training program comprising at least 10 landmark procedures is required to achieve optimal skills.

The paper raises some interesting ethical and training issues. It doesn’t seek to address them though. These issues are by no means specific to CVC placement.

Interested to hear your thoughts.

JAMES IS AN ICU&ANAESTHETIC REGISTRAR CURRENTLY UNDERTAKING A CRITICAL CARE ECHO FELLOWSHIP IN OXFORD AND IS THE COAUTHOR OF THE JICS PODCASTS