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 – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61682-2/abstract
  • 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)

http://www.nejm.org/doi/full/10.1056/NEJMoa1500896?query=featured_home

The last in the trilogy of EGDT trial.

Conclusion

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)

http://www.nejm.org/doi/full/10.1056/NEJMoa1500704?query=featured_home

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)

http://www.nejm.org/doi/full/10.1056/NEJMoa1415236?query=featured_home

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 – http://www.nih.gov/precisionmedicine/

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

Recommendations

  • 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 (http://www.ncbi.nlm.nih.gov/pubmed/20484098) In OHCA patients with no obvious extra-cardiac cause, a significant proportion will have abnormal coronaries found at angiography.

Prognostication post cardiac arrest – http://www.ncbi.nlm.nih.gov/pubmed/25398304

Summary

  • 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 – http://ccforum.com/content/18/5/570

Targeting blood pressure (JL Teboul)

Hemodynamic variables related to outcome in septic shock – http://link.springer.com/article/10.1007/s00134-005-2688-z

Use vasopressors even when hypovolaemia has not been completely resolved

Target higher BP if

  • Normally hypertensive
  • Elevated CVP
  • Increased abdominal pressure

SEPSISPAM Review – http://www.wessexics.com/The_Bottom_Line/Review/?id=8374465647407990060

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 – http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=4919825102268844793

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

Conclusion

  • 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 – http://www.wessexics.com/The_Bottom_Line/Review/?id=5706582478459911170

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

Summary

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 – http://www.esicm.org/upload/Protocol_FENICE07_11_2012Final.pdf

http://www.esicm.org/research/fenice

Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. – http://www.ncbi.nlm.nih.gov/pubmed/23774337

Conclusion

  • 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 – http://www.ncbi.nlm.nih.gov/pubmed/19299788

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.
Advertisements

One thought on “ISICEM 2015 Blog Day 1

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s