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 – http://www.thelancet.com/journals/lancet/article/PIIS0140673605670614/abstract Summaries of the trials – http://lifeinthefastlane.com/ccc/pulmonary-artery-catheter-literature-summaries/

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 – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625408/

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? – http://ccforum.com/content/18/2/215 Deep hypothermic circulatory arrest: real-life suspended animation. – http://www.ncbi.nlm.nih.gov/pubmed/23993241

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

References Ischemia/Reperfusion Injury in Liver Surgery and Transplantation: Pathophysiology – http://www.hindawi.com/journals/hpb/2012/176723/ Nitric Oxide in Liver Injury – http://onlinelibrary.wiley.com/doi/10.1002/hep.510300148/pdf

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

Conclusions

  • 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

References RAPID PREDICTION OF TRAUMA PATIENT SURVIVAL BY ANALYSIS OF HEART RATE COMPLEXITY: IMPACT OF REDUCING DATA SET SIZE – http://journals.lww.com/shockjournal/Abstract/2009/12000/Rapid_Prediction_of_Trauma_Patient_Survival_By.1.aspx

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

References http://www.sensocure.no/

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

Conclusion

  • 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 – http://www.biomedcentral.com/1471-2466/14/72

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 – http://www.ncbi.nlm.nih.gov/pubmed/22990871 Bedside Ultrasound Assessment of Positive End-Expiratory Pressure–induced Lung Recruitment – http://www.atsjournals.org/doi/full/10.1164/rccm.201003-0369OC#.VQs2iNKsUlI

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 – http://www.criticalcarecanada.com/presentations/2014/a_new_classification_for_patients_weaning_from_mechanical_ventilation.pdf Cochrane review – http://www.cochrane.org/CD008638/ANAESTH_smartcaretm-versus-non-automated-weaning-strategies-for-weaning-time-in-invasively-ventilated-critically-ill-adults

Brain protection (A Maas)

http://www.tbi-impact.org/ 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. – http://jama.jamanetwork.com/article.aspx?articleid=1386591

Vasopressor therapy (JL Vincent)

Noradrenaline remains vasopressor of choice Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis – http://www.ncbi.nlm.nih.gov/pubmed/22036860 No magic BP Timing of norepinephrine in septic patients: NOT too little too late – http://ccforum.com/content/pdf/s13054-014-0691-x.pdf 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 – http://ccforum.com/content/19/1/18 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. – http://jama.jamanetwork.com/article.aspx?articleid=195197 Hydrocortisone Therapy for Patients with Septic Shock. CORTICUS – http://www.nejm.org/doi/full/10.1056/NEJMoa071366 ADRENAL Trial – https://clinicaltrials.gov/ct2/show/NCT01448109 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.
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