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

8.png(@Doctor_J_)

Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

Source control needs to be rapid.

9.png(@david_menzies)

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

11.png

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

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