ISICEM 2016 Day 2

Adrian strikes again with a neat summary of his second day in Brussels JS

How we decide

Protocols and guidelines: misaligned and misdistributed (Kavanagh)

Do protocols work in CCM?

Sevransky Crit Care Med 2015: Protocols and hospital mortality in critically ill pts

They don’t help – no difference in outcomes BUT not related to protocol compliance

Hypothesis:

Protocols surely do some good in some settings but overall the net impact is nil… therefore protocols must do harm in some settings!!

 

WHY DON’T THEY WORK

  1. Protocols misattribution

Hayes et al NEJM 2009 Surgical Safety Checklist to Reduce Mortality and Morbidity – 1/3 less complications which was attributed to implementation of key ‘processes’

BUT did increase implementation cause improved outcome?

NO concordance, almost perfect discordance – no ‘cause and effect’

DO NOT RELY ON CHECKLIST!

2) Protocols misalignment

Variation in hospitals settings e.g. basics vs advanced, primary vs tertiary

  1. Could sophisticated setting work in rudimentary setting? NO e.g. FEAST trial.
  2. Could rudimentary protocol work in sophisticated setting i.e. dumbdown? NO

Standardized Intensive Care. Protocol Misalignment and Impact Misattribution
http://www.atsjournals.org/doi/abs/10.1164/rccm.201502-0314CP#.Vulm8hIrKRs

IMG_7489

Situation where good

  • non-Tacit knowledge: difficult to put into words, demands talent, requires practice e.g. playing flute
  • Issue is simple and explicit
  • Reduce variability e.g. ECMO (caveat no variability = no health care research)
  • Research

In research, protocols need to be followed exactly. BUT expert clinicians nee to be more flexible.

IMG_7492

Conclusion

  • Avoid misattribution
  • Avoid misalignments
  • Understand limitations of protocols
  • Assess protocols as drug
  • Understand need for protocol in research
  • Understand why you need protocol IF you need protocol because of lack of staffing or expertise, address this first!

 

Why don’t all ICUs use SDD? (A Gordon)

WHO Report on burden of healthcare infections

Selective decontamination of the digestive tract: the mechanism of action is control of gut overgrowth

Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis

Use of SDDT in UK ICU Bastin and Ryanna – 192 UK ICUs only 10 did

Decontamination of the digestive tract and oropharynx in ICU patients.

 

SDD does require consensus amongst my colleagues – you need a champion

New evidence R-GNOSIS RCT in 12 European ICUs – http://cordis.europa.eu/result/rcn/163125_en.html

 

How personal biases influence decisions (Funk)

Illustrated by case of misdiagnsosis

Cognitive biases

Two modes of thinking (Kahnemann)

  • Fast – automatic and effortless, associations and heuristic
  • Slow – active reasoning and effort, calculations and probability

Dunning Kruger effect – unskilled doctors overestimating their ability; very skilled doctors underestimating their ability

Status quo bias – slow to change. Ignore new evidence in favour of current practice e.g. sedation, SDD

Sunk cost fallacy – when you’ve invested so much, you keep going

Omission bias – someone starts unnecessary drug (in case), and another who fails to stop it

Omission bias and decision making in pulmonary and critical care medicine CHEST 2005 128 1497

Bias blind spot – we think are not bias

De-biasing is possible

Protocols promote familiarity and hence development the clinicians’ “gut-feeling”

 

The influence of human factors: Looking into the mirror (Brett)

Humans are variables

Thought outside the box: ICU freakonomics and decision making in ICU (reference)

Rationale economics doesn’t make sense – if we have an emotional attachment or bias, we make foolish decisions

A lot of what we do is pattern recognition

IMG_7499

Different ppl in teams may not see/hear the same thing – FEEDBACK/READ BACK AT END OF ROUND IS IMPORTANT

 

The therapeutic conflict: When each of your decisions may cause harm (Perel)

Therapeutic conflicts are common especially in pts with MOF. E.g. septic pts with ARDS, how do you manage fluids. 30mls/kg advocated by SSC

Marik and Bellomo: A rational approach to fluid therapy BJA 2015 – most septic pts are not fluid responders

 

How to approach?

  1. Recognise there is a conflict – ask if the pt can afford the mistake your decision might result in?
  2. Gain more information – Acting in the Face of Uncertainty: Annals Int Med 2014. Combine and integrate parameters
  3. Identify the most critical problem
  4. Choose the least potentially harmful option
  5. Make decision and closely follow its results
  6. Repeat steps from the top

 

Changing strategies at the right time (Hall)

IMG_7504

 

 

How to implement changes (Stelfox)

Research should inform changes to clinical practice (discover new rx, replace current rx or reverse current rx)

BUT there is a 17 year journey from bench to clinical practice

  • Limited knowledge on implement science
  • Inefficient dissemination method
  • Inadequate assessment of cost and societal values
  • Science and clinical communities operating in isolation

The story of tight BM control on ICU; LEUVEN 1 (good) à NICE-SUGAR (bad)

Predictors of adoption – teaching vs non-teaching hospital, medical vs surgical admission

 

LOOKING AFTER THE ICU TEAM

ICU Nurses: A physician’s perspective

So important and respected (especially by patients)

The nurses role 4Cs – convening, checking, caring and continuing

Developing a model of interprofessional shared clinical decision making in the ICU Crit Care Med 2016 – http://journals.lww.com/ccmjournal/Abstract/2016/04000/Development_of_a_Model_of_Interprofessional_Shared.5.aspx

 

The forgotten family: caregivers (Herridge)

Informal caregivers are given very little support

Caring for Caregivers of the Chronically Critically Ill – http://ajcc.aacnjournals.org/content/20/1/24.full

Post-ICU Syndrome – http://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspx

Mortality after the Hospitalization of a Spouse – http://www.nejm.org/doi/full/10.1056/NEJMsa050196

RECOVER Programme

IMG_7529

 

Burnout and Moral Distress

Increasing problem

Definitions

Burnout Syndrome in Critical Care Nursing Staff – http://www.atsjournals.org/doi/full/10.1164/rccm.200606-806OC#.VukunxIrKRs

High Level of Burnout in Intensivists: Prevalence and Associated Factors –  http://www.atsjournals.org/doi/full/10.1164/rccm.200608-1184OC#.Vuku3hIrK34

Causes of moral distress theme : EoLC, communication, complex pts, bed capacity strain

Intervention (pic)

IMG_7526IMG_7527
Summary (pic)

 

 

Vasoactive drugs in septic shock

Noradrenaline (JL Teboul)

Early NA increases cardiac preload and CO – crit care 2010 14 R

Due to redistributive effect from unstressed to stressed volume

OK as unstressed volume is abnormally increased during sepsis and further overfilled by volume

5 reasons to start NA

Cdq-TT0XIAA0U6j.jpg-large

Start it when diastolic BP is low

 

High high should we go? (Martin)

NE: not too much, too long – http://www.ncbi.nlm.nih.gov/pubmed/26125087

HIGH-DOSE NOREPINEPHRINE TREATMENT: DETERMINANTS OF MORTALITY AND FUTILITY IN CRITICALLY ILL PATIENTS http://ajcc.aacnjournals.org/content/22/1/22.full.pdf

Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4641698/

 

Beyond 1mcg/kg/min do not switch to other catecholamine

 

Vasopressin (Gordon)

Cochrane review: http://www.cochrane.org/CD003709/ANAESTH_vasopressors-hypotensive-shock

The cardiopulmonary effects of vasopressin compared with norepinephrine in septic shock.

http://www.ncbi.nlm.nih.gov/pubmed/22518026

VASST Trial – http://www.nejm.org/doi/full/10.1056/NEJMoa067373

Anthony Gordon presenting the VANISH Trial @ICSmeetings #icssoa2016 soa.ics.ac.uk/2015/12/16/van…

Vasopressin not superior to Norad

Alternative inotropes

  • Levosimendan: calcium channel sensitiser, K-ATP activator
  • LEOPARDS trial

 

Vasopressin analogues in septic shock (Russell)

Norad doses vary widely between RCTs

Selepressin Evaluation Programme for Sepsis-Induced Shock – Adaptive Clinical Trial (SEPSIS-ACT) – https://www.clinicaltrials.gov/ct2/show/NCT02508649

Kanji et al J Crit Care 2014 Echocardiography guided care – http://www.sciencedirect.com/science/article/pii/S0883944114001464

Selepressin in septic shock – http://journals.lww.com/ccmjournal/Citation/2016/01000/Selepressin_in_Septic_Shock___A_Step_Toward.29.aspx

Summary

  • NE doses vary widely between RCTs
  • Excessive NE associated with organ dysfunction and mortality
  • Vasopressin and selepressin decrease NE requirement
  • Selepressin also moderates permeability injury more than vasopressin

Angiotensin 2 (Chawla)

Intravenous angiotensin II for the treatment of high-output shock (ATHOS trial): a pilot study – http://ccforum.biomedcentral.com/articles/10.1186/s13054-014-0534-9

IMG_7539

 

Vasodilators (Bakker)

Vasodilators are counterintuitive in hypotensive pts

Effects of thoracic epidural anesthesia on survival and microcirculation in severe acute pancreatitis: a randomized experimental trial – http://ccforum.biomedcentral.com/articles/10.1186/cc13142

Nitroglycerin reverts clinical manifestations of poor peripheral perfusion in patients with circulatory shock – http://ccforum.biomedcentral.com/articles/10.1186/cc13932

Testing a conceptual model on early opening of the microcirculation in severe sepsis and septic shock: a randomised controlled pilot study – http://www.ncbi.nlm.nih.gov/pubmed/25032942

Conclusion

  • Vasodilation optimizes venous pressure in pts with hypotension.
  • Nitroglycerin infusion improves microcirculation and lowers CVP

 

Nitric Oxide (De Bakker)

NO has a role in regulating microvasculature

NO synthase enzyme has several forms – constitutive and inducible

Non-selective NO inhibitors in pts with septic shock and are unlikely to be of value

 

IMG_7542

Beta-blockers in sepsis (Singer)

Some sympathetic activation is necessary and good. BUT too much of a good thing, or if it persists for too long, is bad.

Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress – http://www.nejm.org/doi/full/10.1056/NEJMoa043046

Catecholamine treatment for shock–equally good or bad? – http://www.ncbi.nlm.nih.gov/pubmed/17719998

Nonselective beta-blockade enhances pressor responsiveness to epinephrine, norepinephrine, and angiotensin II in normal man. –

http://www.ncbi.nlm.nih.gov/pubmed/6705443

Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock – http://jama.jamanetwork.com/article.aspx?articleid=1752246

IMG_7544

 

 

 

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