Critical Care Reviews meeting 2016 blog – Session 1

Critical care reviews is a one day meeting in Belfast by Rob Mac Sweeney and the Northern Ireland Intensive Care Society.  Adrian Wong and Jamie Strachan attended and have put together these notes for oxicm. Rob is going to put all the talks online over the next few weeks.

The Great Debate: RCTs are Killing Critical Care

Jean-Louis Vincent (@jlvincen): Damn Right!

We should abandon randomized controlled trials in the intensive care unit.

-Fluid, BP, Hb, feeding all have been RCTed to show no benefit.

-Chest compression has never been RCTed and yet we still use and continue to investigate around its “fringes” e.g. LUCAS, continuous vs interrupted.

-Its the process of care NOT the actual RCTs that have advanced ICM.

-In conclusion, JLV advocates personalized and precision treatment plans

Luciano Gattinoni (@gattinon): You’re Having a Laugh?

The logic of RCTs and scientific reasoning

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– It is not the RCTs but the interpretation and implementation of their findings that is the problem.

– Are we (all) too quick to throw away treatments after RCT? ECMO was discarded for 30 years after 1970 says @gattinon

– Problems with RCTs – premise and external validity. Not asking the right question – Wrong study=wrong result

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Discussion

JLV and Gattinoni both say – we are asking the WRONG questions.

Interesting articles

Paul Young (@DogICUma): Saline or Plasmalyte? Is SPLiT the Solution?

Great discussion on this trial – well covered online in other places:

Original paper | Editorial to manuscript |@WICSBottomLine Review | @stemlyns Review

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New data from Young was presented at this meeting however:

 

But this a non-significant result and was from a post hoc analysis of a non predefined subgroup, as Simon Carley pointed out from the twittersphere:

What it did do is help Dr Young and his colleagues with their next project- the PLUS trial: PlasmaLyte versus Saline trial – 40 sites, 8800 pos ? the definitive trial comparing plasmalyte and saline.

John Holcomb: How to Resuscitate PROPPRly

Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma The PROPPR Randomized Clinical Trial

Again well covered elsewhere but a great run through today from John:

@WICSBottomLine Review | @stemlyns Review | @theSGEM Review

Other points:

– plasma is a drug with thousands of proteins in it

– Holcomb explains survival bias: Did they live because they got the whole blood or did they live long enough to get the whole blood?

– PROMMTT data: “transfusion was random across centres”

– KM Curves in PROPPR already started separating within 3 hours

– Median time to haemorrhagic death in trauma 2.5hrs. It is products we give before this time that hold importance

– No point of care coagulation test is fast enough to keep up in active bleeding.

Tim Walsh (@Ed_TimWalsh): Is Old the new Young? The ABLE Trial

Age of Transfused Blood in Critically Ill Adults | @WICSBottomLine Review

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The conclusion?  – Fresh red cells do not appear to be superior to standard issue red cells in critically ill adult patients.

Tim Walsh made the great point that so-called negative randomised control trials can reassure us we are doing no harm.

 

Critical Care Reviews meeting 2016 blog – Session 2

Critical care reviews is a one day meeting in Belfast by Rob Mac Sweeney and the Northern Ireland Intensive Care Society.  Adrian Wong and Jamie Strachan attended and have put together these notes for oxicm. Rob is going to put all the talks online over the next few weeks.

Session 2 was “How i manage…”

Luciano Gattinoni (@gattinon): Hypoxaemic Respiratory Failure

Know the baseline sats and RR (without O2) – response to oxygen tells you about the shunt

Knowing the PaCO2 tells you how much tired the patient is

If sats don’t improve with O2, shunt fraction is close to 30%

Gattinoni would intubate moderate/severe ARDS immediately

Know the diagnosis and the treatment! Don’t just manage ARDS

Test the oxygenation at PEEP 5

When increasing PEEP, measure central venous oxygenation and check scvO2. If scvo2 & paO2 both go up good. If 1 goes down serious harm instability

Friday night ventilation: a safety starting tool kit for mechanically ventilated patients

Jean-Louis Vincent (@jlvincen): Septic Shock

Give antibiotics – early and the correct ones

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Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

Source control needs to be rapid.

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Microorganism is ultimately discovered in 77% of @jlvincen septic patients

So de-escalate antibiotics – quickly if you can

10.pngVIP – ventilate, infuse and pump

Individualise the fluid strategy

The phases of fluid strategy – SOSD – salvage, optimize, stabilization, de-escalation

Four phases of intravenous fluid therapy: a conceptual model

Don’t touch pt during fluid challenge!

Passive leg raise – but it’s too complicated. Just give fluid challenge and watch cardiac output

JLV – start noradrenaline early and he would start dobutamine

Concept of SEPSIS Team

Paul Young (@DogICUma): Pyrexia in ICU

Acetaminophen for Fever in Critically Ill Patients with Suspected Infection

@WICSBottomLine Review

Paul had 6 take home messages:

  1. “Converting peripheral temp to core by adding 0.5 is a bit dodgy”
  2. “The temperature that is not on the chart is not as accurate as you think”
  3. “If temperature >39 intermittently, consider continuous monitoring”
  4. “If temperature control is important, I typically administer paracetamol regularly”
  5. In morbidly obese, external cooling may worsen things initially because of vasoconstriction
  6. 48hrs of ibuprofen appears to be safe and well tolerated in sick ICU pts

Young: Keep the pts alive for long enough so that they will get better themselves

John Holcomb: Traumatic Haemorrhage

Think about 2am medicine when planning strategies/guidelines

Most trauma deaths occur within 1 hr

Moving thawed plasma from lab to ED, reduced time of administration by 40 minutes

No blood test is fast enough to manage the initial phase – No point in lab tests whilst pt actively bleeding. Goal directed transfusion starts when bleeding stops

“Giving blood does not stop bleeding”

How I treat patients with massive hemorrhage

Tim Walsh (@Ed_TimWalsh): Anaemia in ICU

Anaemia is common

Causes of anaemia on ICU

  • Haemodilution
  • Blood letting
  • Blood loss
  • Marrow suppression
  • Iron met supprssn
  • Chronic disease
  • Reduced RBC life

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10 good practice points:

  1. Transfuse blood when it obviously saves lives
  2. What does Hb mean – concentrated etc
  3. Avoid excessive blood letting
  4. Don’t routinely administer iron – IRONMAN trial awaited
  5. Don’t administer erythropoietin
  6. Use single unit RBC transfusion in non-bleeding pts
  7. Early sepsis might be different BUT only when there is a clear evidence of tissue hypoxaemia
  8. Make individual judgements for the pt with cardiovascular disease
  9. Don’t ask for fresh blood
  10. Don’t transfuse unless Hb<7 in young, healthy pt

Restrictive versus liberal transfusion strategy for red blood cell transfusion: systematic review of randomised trials with meta-analysis and trial sequential analysis

Critical Care Reviews meeting 2016 blog – Session 3

Paul Young (@DogICUma): Should we treat the HEAT?

WICS Bottom Line review

What is the point of fever?

Helps fight infection in animals…

  • Mice and klebsiella
  • Pigeons and pneumococcus
  • Bees and fungal infections

The higher the temperature in first 24 hours in those with an infection, the lower the mortality

In pre-defined analysis of survivors and non-survivors, paracetamol seem to prolong life of these non-survivors

Reasons that this might be:

Paracetamol blocks oxidative stress. Maybe it’s useful in delaying death and facilitate a window for recovery in ICU?


Anthony Gordon (@agordonICU): Vasopressin or Noradrenaline: should either VANISH?

VANISH isn’t published yet (its not quite through the peer review process!) but it has been presented at meetings so is fair game for a quick summary…

Untitled2UntitledThe role of vasopressin differs in health and shock/septic shock.

VASST trial

VANISH trial design

Vasopressin did point towards an increase in digital ischaema vs norad (although Confidence interval crosses zero)

As promised Anthony Gordon would:

  • 1st line Noradrenaline
  • add vasopressin earlier but no magic number
    • Especially if renal dysfunction developing or arrhythmias/tachycardias
  • Care with vasopressor combination especially in combination
  • Steroids

Pending Rob releasing this talk or the paper coming out, try this from December:

Tim Walsh (@Ed_TimWalsh): Does Rehab help ICU patients RECOVER?

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting

Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge The RECOVER Randomized Clinical Trial

Pts refused trial as they were “too tired”.

NO benefit shown except for some pt satisfaction scores – but is this a reflection of their premorbid state? So RECOVER hasn’t shown a benefit despite all the investment and application of “seems like a good idea”

Cost of intervention is £700 per patient treated

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness

Christopher Nutt (@nuttchristopher) 2015 Critical Care Literature: The Best of the Rest

*Chris stepped up when Rob “The Machine” MacSweeney broke down.

Amongst the numerous studies discussed……. YOU HAVE TO LISTEN TO THE RECORDING. All the important 2015 trials summarised in 25 minutes! And try and beg/borrow/steal the outstanding conference book.

EUROTHERM – worse neuro outcome and mortality in intervention group

EPO-TBI

ICEREA – Endovascular versus External Targeted Temperature Management for Out-of-Hospital Cardiac Arrest Patients: A Randomized Controlled Study

Effect of Corticosteroids on Treatment Failure Among Hospitalized Patients With Severe Community-Acquired Pneumonia and High Inflammatory Response

FLORALI

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome

PERMIT Trial

TiTRE2 Trial
3 SITES Study

 

Critical Care Reviews meeting 2016 blog – Session 4

Session IV

Panel Discussion 2015 Critical Care Literature – What I Thought of It

(This blog does no justice to the quality of discussion that occurred. Watch out for the recordings.)

EuroTHERM – the fallout when a trial is stopped early.

NO data on paracetamol as one of the most commonest drug used in the world

Holcomb: Let’s make sure we understand the basic of what we do everyday before we start looking at new things.

Less is more – least, most, minimum

Paul Young – Lancet paper on hypophosphotaemia and feeding strategy (DogICUma’s best of the rest paper of the year). Needs an answer re: nutrition – TARGET trial

Antony Gordon – stem cell therapy

Holcomb – prehospital blood products. Closed-loop technology to aid clinical decision making

Walsh – transfusion targets in high risk CVS pt. Blood products for invasive procedures such as line insertion on ICU

John Hinds’ Trauma Lecture: Brian Burns (@HawkmoonHEMS) Trauma Care – Back to the Future

Adrian’s personal note: I have known about John’s work through the wonders of social media for a while before finally meeting him in person at SMACC2015. 2 things struck me when we first met – 1) cool, he has kept the ponytail and 2) he isn’t very tall. But after talking to him, his passion, enthusiasm and humility was my overwhelming impression of him. If you’ve never heard him speak, have a listen to these two talks – they are brilliant.

Crack the chest: Get cruxified

Cricolol

A great tribute to start with John’s helmet on stage.

The range of topics presented

  • Blood products
  • Tranfers/MTC
  • REBOA
  • Impact Brain Apnoea – role of brainstem, role of catecholamine surge
  • Traumatic cardiac arrest – Algorithm from HEMS