ISICEM 2015 Blog Day 3

adrianAdrian Wong‘s third and final day at the International Symposium on Intensive Care and Emergency Medicine in Brussels summarised for OXICM

Edited by Jamie Strachan

What’s changed in for me in the last 35 years? Reflecting on ICM over the last 35 years

CPR (P Pepe)

The growth of CPR, more non-doctors were being trained. Increased availability of AED Changes and increased importance of chest compression 15:2 à 30:2 à interrupted Other considerations

  • Decreased priority of advanced airway management and drug administration (no atropine, bicarb, etc)
  • Head up or head down position for CPR?

Haemodynamic Monitoring (S Magdar)

1970s – Swan Ganz catheter All the focus was on the left heart (cardiology driven) Future Less and less people know how to use a PA Catheter

  • Move towards less/non-invasive cardiac output monitor
  • Move towards flow directed therapy instead of pressure values

References PACMAN Trial – Summaries of the trials –

Circulatory shock (JL Vincent)

The origins of the word shock – probably the battle field Focus was predominantly on BP The triangle of shock

  • Arterial hypotension
  • Increased blood lactate
  • Altered tissue perfusion – oliguria, impaired skin perfusion, altered mental status

Less invasive monitoring, MORE ECHO ScvO2

  • <70% – more fluids, transfusion, dobutamine
  • >70% – nothing

Nutrition (J Wernerman)

Patients were starving on the ICU Nutritional routines 1980

  • Parenteral nutrition (only)
  • Hyperalimentation
  • Macronutrients in components
  • Use of lipid emulsion
  • High amino acid (protein) intake
  • Gastric tube only for evacuation

Most important development 1980 – 2015

  • High class EN products
  • High class tubings for EN
  • All-in-one formulations for PN
  • Better glucose control
  • Electronic PMSs for adequate balances

NB – 4/5 of these were developed without RCTs and the last was a highly controversial RCT

Renal support (C Ronco)

AW – The development and evolution of renal replacement therapy is truly the stuff of legends Multiple devices were needed for what is now a single machine – pumps, warmer, pressure sensors, filter There is paradigm shift from renal replacement therapy to renal support therapy. Previous absolute indication as now relative.

ARDS management (A Pesenti)

1980 – 2015

  • ARDS is a hypoxaemic disease
  • ARDS is (in part) an iatrogenic disease
  • The rise of the idea of lung protection
  • Mechanical ventilation is dangerous
  • We breath to eliminate CO2
  • If we eliminate CO2 by mechanical ventilation, we will be free to breath as little or as much as we wish

References Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS. The prospective randomized Xtravent-study –

The next 35 years

Suspended animation (P Radermacher)

Rationale – to reduce O2 demand Earliest reports date by to 1862 Modern day experiments achieve this by either inducing hypothermia or drugs e.g. NO, H2S Selected references Is pharmacological, H2S-induced ‘suspended animation’ feasible in the ICU? – Deep hypothermic circulatory arrest: real-life suspended animation. –

Inhaled NO to limit ischaemia/reperfusion injury (M Ramsay)

References Ischemia/Reperfusion Injury in Liver Surgery and Transplantation: Pathophysiology – Nitric Oxide in Liver Injury –

Cardiorespiratory monitoring (M Pinsky)

Future CV monitors need to be

  • Continuous
  • Non-invasive
  • Metabolic targets/parameters

These parameters can then be analysed in a combined fashion to predict how patients will respond. These will

  • Define cardiorespiratory state – NOWCASTING
  • Predict onset of cardiorespiratory insufficiency
  • Predict response to therapy – FORECASTING
    • Linking monitoring to management

Healthcare systems linked

  • Telemedicine will be the norm
  • We will not monitor patients, we will monitor the monitors
  • We will still treat the patients not the monitors
  • Healthcare recourse need per unit will decrease drastically by these approaches, as quality of care improves


  • Non-invasive, continuous, metabolic
  • Although one size does not fit all, one knowledge base serves all
  • Linked in real-time to electronic libraries
  • NOWCASTING – illness severity
  • PREDICTING – future instability
  • FORECASTING – response to therapy to reach sufficiency


Implantable Biosensors (TI Tonnessen)

Early warning à early actions Types of biosensors

  • In vitro
  • Non-invasive
    • Not penetrating the skin or mucous membranes
  • Invasive
    • In the blood stream (arterial or venous)
    • In an organ/tissue

Future of biosensors

  • Miniaturisation
    • Insertion without damage to the organ
    • Multiple sensors in the body
  • New material
    • Biofouling
    • Biocompatible
  • Wireless technology
    • Transmission of signals
    • Wireless energy/charging


Monitoring cell happiness (M Singer)

  • No perfect marker (as yet) of early tissue hypoperfusion
  • Some organ beds affected earlier than others
  • All current tools are relatively late, global and non-specific.. but still useful indicators of unwellness
  • Monitoring (adequacy of) tissue oxygenation has to be where it’s at


  • Major component of acute patient management are
    • Rapid restoration of adequate tissue perfusion
    • Prevention of new-onset tissue hypoperfusion
  • Still waiting for the perfect happy cell-o-meter

Monitoring breath (M Schultz)

The development of the electronic ‘nose’ Exhaled breath profiling for diagnosing acute respiratory distress syndrome –

Easy lung imaging (D Chiumello)

The use of various modalities to determine lung recruitment in ARDS

  • Ultrasound
  • Low dose CT
  • PET guided

References Visual anatomical lung CT scan assessment of lung recruitability – Bedside Ultrasound Assessment of Positive End-Expiratory Pressure–induced Lung Recruitment –

Automated respiratory support (L Brochard)

Automated weaning is an example of a Closed-loop system WIND Study group – A NEW CLASSIFICATION FOR PATIENTS WEANING FROM MECHANICAL VENTILATION – Cochrane review –

Brain protection (A Maas) Aim to optimise the design and analysis of clinical trials in TBI, to increase the likelihood of demonstrating benefit of a truly effective new therapy or therapeutic agent

Closed-loop glucose control (R Hovorka)

  • Closed-loop systems are the way forward in glucose control
  • Commercialisation difficult in post NICE-SUGAR Era
  • Outcome studies in glucose control should use closed-loop systems

My propositions for the next SSC guidelines

Mechanical ventilation (T Thompson)

SSC 2012

  • Vt 6
  • Pplat 30
  • Higher PEEP for more severe
  • Recruitment maneuvers
  • Prone for P/F < 100 if experienced
  • Elevation HOB
  • Minimise NIPPV use
  • Weaning protocol
  • No routine use of PAC
  • Conservative fluids
  • No beta agonists

Potential changes

  • Vt 6 as preventative measure
  • Consider proning at P/F 150
  • Centres need to get experience in proning

References Association Between Use of Lung-Protective Ventilation With Lower Tidal Volumes and Clinical Outcomes Among Patients Without Acute Respiratory Distress Syndrome. A Meta-analysis. –

Vasopressor therapy (JL Vincent)

Noradrenaline remains vasopressor of choice Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis – No magic BP Timing of norepinephrine in septic patients: NOT too little too late – Recommendations

  • NA is vasopressor agent of choice (maybe in the future other agents will decrease the need for catecholamines)
  • Optimal blood pressure must be individualised
  • Early vasopressor therapy may be necessary to avoid hypotension
  • Vasopressor therapy should not mask hypovolaemia

Fluid resuscitation (JL Teboul)

Limitations of respiratory variability indices

  • Impossible to predict in SV
  • Impossible to predict in arrhythmias
  • Difficult to interpret if TV too low
  • Difficult to interpret if lung compliance too low
  • Difficult to interpret in case of high frequency ventilation
  • Difficult to interpret under open-chest conditions
  • Difficult to interpret in case of severe RV failure

Passive leg raise – Echo to help assess fluid responsiveness

Steroids (C Sprung)

Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. – Hydrocortisone Therapy for Patients with Septic Shock. CORTICUS – ADRENAL Trial – 2012 recommendations We suggest not using intravenous hydrocortisone as a treatment of adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). If this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200mg per day (grade 2C). This differed from original guidelines which suggested using steroids in patients who had refractory hypotension – phrasing changed. With current body of evidence (and awaiting results of ADRENAL trial), steroids will probably not be recommended in next SCC guidelines.

Adrian Wong is a CUSIC fellow at the John Radcliffe Hospital, Oxford.

ISICEM 2015 Blog Day 2

adrianAdrian Wong is at the International Symposium on Intensive Care and Emergency Medicine in Brussels and summarises his second day here for OXICM

Edited by Jamie Strachan

ICU Organisation

How much intensive care do we need? (G Rubenstein)

Huge variation in ICU bed provision. Not all patients at the same risk of death have the same chance of benefit from the ICU due to individual hospital variation.

In some cases, patients are admitted to ICU because you don’t want to admit them to the ward.


Studies are limited by the fact that its difficult to define what is an ICU bed or even what is an intensivists.


Variation in critical care services across North America and Western Europe –

Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis –

Access to urban acute care services in high- vs. middle-income countries: an analysis of seven cities –

Pros and Cons of separate step-down beds (H Wunsch)

Discharging a patient from ICU to the ward somethings feels like pushing the patient off a cliff.

Potential benefits of step down bed

  • Better outcomes
  • Better flows
  • Cheaper
  • Reduce need for ICU beds


  • More care transitions
  • More expensive
  • Patient distress


  • Profoundly understudied
    • Terminology remains a problem
  • Very mixed results so far
    • Mortality
    • Length of stay
    • Patient experience
  • Challenges of varied configuration
    • Hospitals with separate stepdown units may be fundamentally different in many ways


Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study –

Does intermediate care improve patient outcomes or reduce costs? –

Setting up an ICU Echo service (S Huang)

Governance profoundly important

Implementing an Echocardiography Service in the Intensive Care Unit –

Keep quality of sleep (JP Mira)

Few studies and highly heterogeneous

ICU patients have a marked reduction in REM Sleep

Integrated strategy to promote sleep

  • Noise reduction
  • Diurnal lighting practices
  • Use of sleep-promoting pharmacological agent
  • Minimising use of pharmacological agents that inhibit sleep
  • Uninterrupted time for adequate sleep
  • Appropriate physiological support
  • Active promotion of patient orientation
  • Patient-ventilator synchrony
  • Relaxation techniques


Sleep in the Intensive Care Unit –

Feasibility Of Conducting 24-Hour Polysomnography Studies In The Medical Intensive Care Unit:

The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients –

Light in the ICU (M Rosengart)


  • Photoperiodism exists in humans
    • Optimal photoperiod to alter human biology in the context of illness remains to be defined
  • Blue spectrum can alter the biology of critical illness
    • Is there human relevance
  • A light of optimal spectrum, intensity and duration of light can be identified and applied to alter human biology and the course of critical illness


The effect of window rooms on critically ill patients with subarachnoid hemorrhage admitted to intensive care –

Light and the outcome of the critically ill: an observational cohort study –

The optimal ICU design (Halpern)

Showcasing some truly beautiful and functional ICUs. Utrecht ICU looks stunning

Modern rooms – e-glass, booms, environment sensors, webcams, etc

Cost – $1,000,000 per room


  • Optimal ICU design requires extensive planning, simulation and attention to detail
  • The focus of ICU design should be on all aspects of
    • The patient room
    • Family needs both inside and outside the patient room


All patients should walk (J Mancebo)


Functional Disability 5 Years after Acute Respiratory Distress Syndrome –

ICU-Acquired Weakness and Recovery from Critical Illness –

Staffing and work culture (D Angus)

Considerable amount of variation – some easily measured and some less easily measured.

Less easily measured

  • Hierarchy
  • Leadership
  • Followership
  • The ‘it’ factor

BUT caveats

  • I’ll know it when I see it
    • A large part of ICU culture has strong ‘smell’ but remains difficult to define
    • You can tell how good a unit is by the ‘feel’
  • Chicken or egg
    • Optimal patient outcome is likely affected by
      • Number and type of staffing composition
      • Competency of staffing
      • Degree of timework and integration
      • Morale and attitudes
    • Easier said than done
      • From easy to hard
        • Provision and training of staff
        • Coordination and integration of care
        • Sense of teamwork and camaraderie
        • Reversing ‘burn-out’ and ‘getting to great’


  • ICU staging, organisation and culture varies a lot
    • Workforce composition, competency and morale
    • Team interaction, cohesiveness and behaviour
  • These factors appear to affect outcome
    • And many can be positively influenced
  • BUT
    • Some of the largest perceived attributes are hard to capture
    • Bi-directional relationship of cause and effect
    • Some important domains are extremely resistant to change

Keep the ICU doctor happy (M Ramsay)

ICU and ED jobs are stressful

Burnout is a syndrome of emotional exhaustion, de-personalisation, and a sense of low personal accomplishment that leads to decreased effectiveness at work –

Sleep deprivation

  • Deceased efficiency
  • Instability
  • Recent memory deficit
  • Depersonalisation
  • Inappropriate humour

Struggling in silence

  • 300-400 physicians die each yer by suicide
  • Methods: OD, firearms
  • Risk factors: depression, alcohol abuse
  • Higher completion/attempt ratio

High reliability organisation

  • Leadership committed to zero harm
  • Safety culture embedded in organisation
  • Robust process improvement
  • Risk management proactive and not reactive
  • Blame free for small errors but accountability for adhering to safe practice

Emotional Intelligence – out of control emotions make smart people stupid


  • Healthcare is 24 hour operation
  • Understanding how fatigue affects doctor is critical to patient safety, performance and productivity
  • An impaired physician is a waste of a valuable resource
  • An impaired physician is a liability to the organisation and medical staff

Pro/Con debate HFOV



Pro (N MacIntyre)

HFOV makes conceptual sense

HFOV has considerable supportive clinical evidence (but in paeds population)

Recent negative clinical trials problematic

  • Lack of expertise
  • High Paw protocol in the setting of high vasopressor use

Con (N Ferguson)

Not for routine lung protection in moderate ARDS

Carefully selected patients with severe ARDS

  • After consideration of prone, NMB

Assess response to HFOV initiation

  • Significant increase in pressor requirements
  • No significant improvement in oxygenation
Adrian Wong is a CUSIC fellow at the John Radcliffe Hospital, Oxford.

ISICEM 2015 Blog Day 1

adrianAdrian Wong is at the International Symposium on Intensive Care and Emergency Medicine in Brussels and has penned this summary for OXICM

Edited by Jamie Strachan

Opening Plenary Session

Say YES to intensive care (J-L Vincent)

Setting the tone on the 35th anniversary of the ISICEM meeting

In the last 35 years, as a specialty, we are doing less and less e.g. transfusion, fluids, tidal volumes

A cautionary note on the endless pursuit of EBM via RCTs. There are a lot of ‘negative’ RCTs (I personally hate the term ‘negative’ trials. It plays done the huge effort put in by the research team). Patients on the ICU are very heterogenous and hence are we surprised that one size doesn’t fit all?

Perhaps a more positive view point is the fact that although mortality is static, the age of our patient has increased. The burden of ICU care should not be underestimated. Patients may benefit from earlier intervention rather than banging on death’s door before being admitted. Accessibility to ICU care needs to be timely.

Closing note – realise the difference between protocolised care vs intelligent care.

Reducing the global burden of sepsis (S Finfer)

Highlights from the roundtable discussion on understanding the burden of sepsis in the global context.

Areas to be tackled

  • Understanding its epidemiology. Data is scarce from countries in Africa and Asia. Global Burden Of Disease Study –
  • The impact of our changing world on the disease
    • Global warming
    • Ageing population
    • More mobile population/Urbanisation
    • Antibiotic resistance
  • Measures to manage sepsis
    • Prevent ICU-acquired sepsis
    • CVS optimisation
    • Infection control
    • Modulation of sepsis response
  • Morbidity the price of success

With improved data we can also improve awareness among health care workers, the public and politicians (World Sepsis Day 13th Sept)

Sepsis success

  1. Reducing case fatality rates in many countries
  2. World Sepsis Day and increasing awareness
  3. Hand hygiene and prevention initiatives
  4. High quality investigator initiated research
  5. International/global collaboration on many fronts

What did you PROMISE? (K Rowan)

The last in the trilogy of EGDT trial.


Primary outcome

  • No difference in all cause mortality at 90 days in EGDT vs usual care (29.5% vs 29.2%)

Secondary outcome

  • SOFA score at 6 hours and 72 hours
    • higher SOFA scores in EGDT but that is due to intervention
  • Receipt of organ support in critical care
    • More CVS support in EGDT
  • Duration of organ support in critical care
    • No difference
  • Duration of stay
    • No difference
  • All cause mortality
    • No difference at 28 days, hospital discharge and at 1 year

Pooled data (Protocolised Resuscitation in Sepsis individual patient data Meta-analysis) – NO DIFFERENCE IN 90 DAY MORTALITY

In adults, presenting to ED with signs of early septic shock, identified early and receiving IV antibiotics and adequate fluid resuscitation – haemodynamic management according to a strict EGDT protocol does not lead to an improvement in outcome.

Transfusion – does the age of RBC matter? (P Hebert)

Fresh (less than 8 days) RBCs vs standard RBCs in order to improve 90 day mortality and morbidity

Fresh red cells do not appear to be superior to standard issue red cells in critically ill patients

SIRS is dead (R Bellomo)

The original definitions of SIRS/Sepsis are now more than 20 years old

Problems with the definition

  • Terminology does not help us understand the underlying problem
  • SIRS is too sensitive but is not specific
  • SIRS does not reflect the severity of the disease process
  • SIRS may detract from the search for infection

82.2% of ICU patients without infection have ‘SIRS’

Patients can have severe sepsis without SIRS i.e. limited sensitivity and yet they have features of major illness

There is no step-up in risk at having 2 SIRS criteria compared to 3 or 4 – lack construct validity

SEPSIS 3.0 (Singer)

Host response is key

Sepsis is not simply a systemic inflammatory response

Variety of anti-inflammatory and other (mal)adaptive responses occur concurrently

Sepsis should be defined as life-threatening organ dysfunction due to a dysregulated host response to infection

Sepsis = really sick infection

No definition is data driven using SOFA score to characterised organ dysfunction

SOFA superior in ICU but poor on ward and ED.

qSOFA – altered mental status, respiratory rate and systolic BP is superior on ward and ED

Personalised medicine is the future (H Wong)

Precision Medicine Initiative –

ICM deals with syndromes and hence needs personalised care

Current diagnostic tests to define subclasses/endotypes of critical illness are too slow

Future would involve multiplate mRNA testing to allow customise therapy based on biologically-defined endotypes

Should we centralise ICU care?

Advantages and problems (D Angus)

Existing critical care

  • Expensive, poorly distributed and stretched thin
  • Care May be better at larger centres
    • Regionalised trauma systems demonstrate potential
  • But, critical care is more complex than trauma
  • Regionalising critical care
    • Potential benefits
    • Some aspects are not that hard, once incentives aligned


  • Demonstrate projects
  • Regional centres
  • Telemedicine
  • Community/Interhospital outreach
  • Hybrids
  • Areas of future research
    • Reasons for volume outcomes
    • Alternative staffing models

ECMO centres (A Combes)

  • Only experienced centres should run ECMO programmes
    • Both VA and VV ECMO, at least 20 cases per year
  • Create regional networks of hospitals
    • Detect early refractory cardiac/respiratory failure
  • Mobile ECMO retrieval tams in all ECMO centres
    • 24/7

Trauma centres (O Grottke)

Probably the most established regionalised/centralised service

Right patient at the right place at the right time for the right treatment

Benefits have been replicated in studies across the globe

Cardiac arrest centres (J Nolan)

Aim is to maximise myocardial and neurological recovery

PROCAT Registry ( In OHCA patients with no obvious extra-cardiac cause, a significant proportion will have abnormal coronaries found at angiography.

Prognostication post cardiac arrest –


  • Logical progression of existing regionalisation
  • 24/7 access to cardiac cath lab
  • Comprehensive post-resuscitation care
  • Neurological support for prognostication
    • SSEP, NSE, continuous EEG
  • Indirect evidence for better outcomes
  • It’s happening anyway!

Early resuscitation in sepsis

What do you mean by early (J Bakker)

Earlier is better

The effect of goal-directed therapy on mortality in patients with sepsis – earlier is better: a meta-analysis of randomized controlled trials –

Targeting blood pressure (JL Teboul)

Hemodynamic variables related to outcome in septic shock –

Use vasopressors even when hypovolaemia has not been completely resolved

Target higher BP if

  • Normally hypertensive
  • Elevated CVP
  • Increased abdominal pressure


Still a place for transfusion (A Perner)

More pts transfused in EGDT vs usual care groups –

  • PROCESS – 14 vs 8%
  • ARISE – 14 vs 7%
  • Rivers 64 vs 19%

TRISS Study review –

How to prevent renal failure (R Bellomo)

Preventing AKI in sepsis

  • Do not give starch
  • Do not give gelatin
  • Do not give NSAIDs
  • Do not give multiple doses of aminoglycosides
  • Do not give long courses of vancomycin
  • Do not give amphotericin
  • Consider giving chloride-poor or chloride physiologic fluids


  • In septic patients renal protection remains elusive
  • Avoid nephrotoxins
  • Probably best ot maintain a MAP close to basal night-time levels
  • Avoid fluid overload
  • Consider vasopressin
  • Consider global (patient) costs
  • Killing the patient while trying to save the kidney is not a good idea

Improvement sepsis performance in the ED (F Machado)

Describe the challenges of implement a change in practice in the ED with regards to sepsis management

Key – multifaceted approach to get people to do what they agree to do e.g. education, training, incentives, etc.

Improving sepsis performance on the ward (R Dellinger)

Quality improvement project to roll out SSC bundles on the wards in a US hospital

Nurses empowered, electronic notes/warning systems

Pharmacist ensures antibiotics are administered within 15 minutes of being prescribed

The essential haemodynamic variables

Interpretation of heart rate (A Morelli)

Tachycardia can be compensatory or non-compensatory

Compensatory mechanisms are only useful over a short time frame

[Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock A Randomized Clinical Trial]

Review –

Arterial pressure (S Magdar)

Step 1 – observe patient. If patient is fully awake, communicating, good colour, urinating, normal BE/lactate, their BP is likely to be adequate. Observe


We are pressure regulated species – arterial pressure is relatively constant under normal conditions

Volume and compliance determine the pressure

CO and SVR determine the central pressure. Central pressure determines the regional flow.

Total energy NOT pressure determines flow – gravitational, elastic and kinetic

CVP (M Cecconi)

FENICE Trial Protocol –

Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. –


  • CVP is an important variable as it is key determinant of venous return
  • Best interpreted when look at
    • Changes CVP
    • Concomitant changes in CO

How to measure pressure accurately (JL Teboul)

Errors in CVP measurement –

Sources of error

  • Inappropriate zero point (anatomical)
  • CVP measured at the foot of c wave
  • CVP and PAOP are measured at end-expiration – will thus depend on SV or IPPV
  • Subtract the estimated PEEP/auto PEEP

How to measure cardiac output accurately? (X Monnet)

Dilution techniques are accurate and should replace PA catheters as the goal standard

Uncalibrated pulse contour analysis

  • SV proportional to amplitude of aortic pressure
  • Relationship is influenced by vascular compliance and resistance. Hence are unreliable in case of changes in vasoactive tone

Volume clamp method e.g. NEXFIN are not very accurate in the ICU setting

CO is not regional blood flow, nor tissue perfusion, but only a part of it

Adrian Wong is a CUSIC fellow at the John Radcliffe Hospital, Oxford.