PINCER - Hot Topics

Academic Department of Critical Care Queen Alexandra Hospital Portsmouth

Hot Topics in ICM

Steve Mathieu @stevemathieu75 @WessexICS

Consultant in Intensive Care Medicine Queen Alexandra Hospital, Portsmouth

27th February 2015

NAP 4 -‐ 2011

•  All NHS hospitals for 1 year ’08-‐’09 •  184 reports

 133 anaesthesia  36 ICU  15 ED

•  Inclusion criteria  death, brain damage  emergency surgical airway

 unanTcipated ICU admission  ProlongaTon ICU stay


Summary of NAP 4

  25% of major airway events in a hospital occur in ICU or the ED

  46% of ICU events and 53% of ED events occurred out of hours

  50% of ICU events were due to tracheostomy related events

  50% events in ICU and 27% events in ED resulted in death

  61% events in ICU resulted in death or severe neurological harm


RecommendaTons

  Capnography   Airway equipment   Back up planning   Staffing   PaTent transfers   EducaTon/training   Tracheostomy tube design   Team working


TracMan -‐ 2013

• Early tracheostomy (by d 4) or late (>10/7)

–  455 paTents –  Mortality the same 31% –  LOS the same 13 d

–  ComplicaTons slightly higher in late group 6% vs. 5%

Young et al. JAMA 2013 May 22;309(20):2121-‐9


ARDS -‐ Incidence

•  1 yr prospecTve observaTonal study; 255 paTents

•  Incidence 7.2/100,000/year (? US 75/100,000)

•  Despite use of lung protecTve venTlaTon overall ICU mortality >40%


ARDS -‐ lots of trials   HFOV   Nitric Oxide   Surfactant   Perflourocarbon   Late steroids (LaSRS)  Prostaglandin E1   Lysophylline (LARMA)  Ketoconazole (KARMA)

  Streptokinase   StaTns (HARP 2, SAILS)   Neutrophil elastase inhibitor

  ImmunonutriTon (Eden-‐Omega)

  rhAPC   Albuterol/salmeterol (BALTI I & II, ALTA)

  Lower Vt   ? Furosemide (FACTT)

  Cisatricurium   Prone ‘back’ in


OSCAR

•  795 paTents with moderate -‐ severe ARDS (<26.7kPa / 200mmHg)

•  CMV vs. HFOV (MV <7 days) •  No difference in

–  30/7 mortality (41%)

–  DuraTon anTmicrobial agents (2/3 chest sepsis)

–  VasoacTve support duraTon –  ICU LOS –  Hospital LOS


OSCILLATE •  548 paTents with moderate -‐ severe

ARDS

•  HFOV vs low Vt/High PEEP CV (MV < 3d) •  Trial stopped early as harm with HFOV

•  HFOV –  Hospital mortality 47% vs 35%

–  More sedaTon

–  More NMBA’s

–  More vasopressors



OSCAR OSCILLATE

29 ICU’s UK 39 ICU’s 5 countries

795 paTents 548 paTents (planned 1200)

PaO2:FiO2 < 200mmHg

Bilateral pulmonary infiltrates MV for LESS than 7 consecuTve days at the point of randomisaTon

PaO2:FiO2 < 200mmHg FiO2 > 0.5 Bilateral pulmonary infiltrates MV for LESS than 3 consecuTve days at the point of randomisaTon

Encouraged to use PC 6-‐8mls/kg and use ARDS protocol for FiO2 & PEEP R 100 venTlator PEEP 11

CV – PC 6mls/kg, 3100 B venTlator Recruitment maneuvers before HFOV Protocol specified high PEEP for CV (PEEP 13)

30d mortality 42% vs. 41% (HFOV vs. CV) 30d mortality 40% vs. 29%

Hospital mortality 47% vs. 35% (HFOV vs. CV)

More NMBA’s More midazolam, vasoacTve drugs, NMBA’s in HFOV

Lower PEEP strategy ? recruitment maneuvers of lung before HFOV injurious

Mortality 41% in control group Mortality 35% in control group

PROSEVA •  466 paTents with severe ARDS •  Prone posiTon vs supine posiTon •  Prone posiTon was associated

with

–  Improved mortality •  28 day: 16% vs 33% •  90 day: 24% vs 41%

–  Less cardiac arrests –  No difference in complicaTons


PROSEVA


HARP 2 -‐ 2014

•  540 paTents ARDS; 40 UK ICUs •  ARDSnet +/-‐ staTn for 28 days (80mg od simvastaTn)

•  Primary outcome –  No difference in venTlator free days at 28d

•  Secondary outcome –  No difference in SOFA, oxygenaTon –  Elevated CK or ALT/AST > in staTn group


StaTns in ARDS

•  MulTcentre, RCT •  RosuvastaTn vs. placebo in ARDS •  StaTn may modulate inflammatory response

•  745 paTents (trial stopped early because of fuTlity)

•  Primary outcome: •  60d mortality: 28.5% vs. 24.9% (staTn vs. placebo) •  VenTlator free days: 15.1 vs. 15.1


StaTn & VAP •  300 paTents with suspected VAP (CPIS

≥ 5)

•  SimvastaTn 60mg vs placebo •  No difference in

–  28d survival –  ICU or hospital mortality

–  DuraTon MV –  Delta SOFA

•  Increased mortality in staTn naieve


BALTI -‐ 2012

•  162 paTents; 46 UK ICU’s •  ARDS & MV

-‐ salbutamol 15mcg/kg/hr or placebo

-‐  Treatment for up to 7 d

•  Mortality greater in those given salbutamol 34% vs 23% at 28d


Steroids in ARDS

•  9 studies (4 RCT’s & 5 cohort)

•  648 paTents •  Trend to reduced mortality but

only ss when result pooled

•  Trials vary ++

1.  Dose 2.  IniTaTon of treatment 3.  Course length 4.  Not all studies report adverse events


Nitric oxide – just say No •  Potent pulmonary vasodilator which when inhaled = selecTve vasodilaTon in well venTlated lung units

•  Improved V/Q mismatch and PVR & PAP •  Also anT-‐inflammatory effects •  SystemaTc review of 12 trials with 1200 paTents = improved oxygenaTon d1, no improvement in mortality

•  !AKI and methaemaglobinaemia "!intracranial bleeding in children Afshari Cochrane review 2007 -‐ adults Barrington Cochrane review 2010 – children Afshari – systema>c review 2011


Magnesium in asthma

•  1200 paTents 2008-‐2012 •  Neb vs. IV Mg vs. placebo •  No role for neb Mg •  Limited role at best for IV Mg

•  Not life threatening asthma

Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-‐blind, randomised controlled trial Goodacre et al Lancet 2013 Vol 1 (4) 293-‐300


VAP


What is VAP?

What are the common organ

isms (early vs.

late?

Scoring systems e.g. CPI

S, HELICS

What anTbioTcs wo

uld you use?

How can you redu

ce incidence

Open Access!#FOAMcc

TTM •  950 unconscious adults; 36 ICU’s •  33°C (n=473) with 36°C (n=466) •  No difference in

–  All cause mortality 33°C (50%) with 36°C (48%)

–  poor neurological funcOon at 180 days

33°C (54%) with 36°C (52%)


CogniTve funcTon post TTM •  652 cardiac arrest survivors from TTM

•  Survival unTl 180 days 52% -‐ invited to follow up

-‐ about half had psychometric tesTng -‐ compared with a control group (STEMI but no cardiac arrest)

•  About 50% had cogniTve impairment •  33 vs. 36 vs. control group similar

•  AyenTon & mental speed more affected in cardiac arrest paTents

•  Memory & execuTve funcToning similar


Pre-‐hospital hypothermia •  Prehospital cooling vs. standard care •  2L of cold normal saline once ROSC •  1,359 OOHCA paTents •  Cooling effecTve (reduced temp) •  No difference

–  Survival to hospital discharge •  VF 63% vs 64% •  nonVF 19% vs 16%

–  Good neurological recovery •  VF 57% vs 62% •  nonVF 14% vs 13%


IABP – SHOCK II •  600 paTents with cardiogenic shock

secondary to AMI

•  IABP vs no IABP •  All received early revascularisaTon

and best medical therapy

•  No difference –  30/7 mortality (40%)

–  ICU LOS, catecholamine, bleeding •  Lancet 2013 Sept – 12/12 results = no

difference in mortality or reinfarcTon rate


VSE in cardiac arrest •  268 paTents in hospital cardiac arrest •  Vasopressin(20IU/CPR cycle) +

epinephrine (1mg/CPR cycle) + methylprednisilone (40mg) vs placebo + epinephrine (1mg/CPR cycle)

•  VSE group –  ROSC at 20 mins higher 84% vs 66%

–  Improved survival to hospital discharge with CPC 1 or 2

–  Improved haemodynamics & cvSpO2

–  Less organ dysfuncTon •  and Academic Department of Critical Care

Queen Alexandra Hospital Portsmouth


ECMO


The oxygenator in veno-‐venous ECMO

ECMO Study type

Year pub

N (ECMO)

N (non

ECMO)

% H1N1

ECMO mortality

Non-ECMO mortality

p

RCT 2009

90 90 0 37% 50% 0.07

RCT 1994

21 19 0 67% 58% 0.8

RCT 1979

48 42 0 90% 92% 0.84

Cohort 2006

32 118 0 47% 29% 0.06

Cohort 2000

62 183 0 45% 39% NS

Cohort 1997

49 73 0 45% 11% <0.001

Case series

2009

68 133 100% 23% 13% 0.06

Case series

2011

69 11 100% 27.5% ?52% ***

ECMO for H1N1 •  2009-‐2010 •  80 paTents referred for ECMO •  69 received ECMO •  22 of these died (27.5%) •  Matching cohort = 52% •  For paTents with H1N1 related ARDS, mortality reduced with ECMO


CHEER •  Refractory cardiac arrest treated with

mechanical CPR, hypothermia, ECMO and early reperfusion

•  26 paTents (11 OHCA; 15 IHCA) •  Primary outcome

–  Survival with good neurological recovery (CPC 1-‐2) 14/26 (54%)

•  Secondary outcomes –  ROSC achieved in 25/26 (92%) of paTents –  Survival to hospital discharge 14/26 (54%)


Passive Leg Raise

CO Monitoring – COMET-‐UK

•  Survey to all UK ICUs •  Respondents

–  Majority used CO monitoring •  Oesophageal doppler 57% •  LiDCO 43% •  PiCCO 42%


How does doppler work? ThermodiluTon?

Pulse contour analysis ?

CO Monitoring


How does doppler work? ThermodiluTon?

Pulse contour analysis ?


•  Meta-‐analysis

•  16 trials inc PEITHO, MAPPETT, MOPETT, TOPCOT

•  Thrombolysis + anTcoagulaTon vs. anTcoagulaTon alone

•  All cause mortality less in thrombolysis group but major bleeding & ICH higher


SEPSIS

The Sepsis Studies


ARISE •  Randomised, controlled, mulTcentre,

•  51 hospitals 1,600 paTents with sepTc shock

•  EGDT vs. Usual Care •  No difference in:

–  All cause mortality at 90d (18%)

–  ICU & Hospital LOS


ProCESS •  RCT 31 ICUs in US

•  03/2008 – 05/2013

•  1351 paTents with sepTc shock •  3 groups

–  EGDT –  Protocol based standard therapy –  Usual care –  No difference in 60 d mortality between groups


Ferrer: Empiric anTbioTcs in sepsis

•  RetrospecTve observaTonal cohort study •  165 ICUs – Europe, US & S America •  Jan 2005-‐ Feb 2010 •  18,000 paTents with sepTc shock •  Delay in anTbioTcs administraTon over first 6 hours azer

idenTficaTon of SS or sepTc shock -‐> increased mortality

•  < 1 hr 24.6%; 1-‐2h 25.9% > 6h 33%


SEPSISPAM

•  RCT, mulTcentre, 29 French ICUs

•  March 2010 – Dec 2011

•  SepTc shock

•  Target MAP 80-‐85 vs. 65-‐70 •  No difference in

–  28 day mortality (high MAP 36.6% vs. 34%)

•  New AF 6.7% in higher MAP group vs. 2.8% P=0.02

•  In chronic hypertension group, worsening creaTnine and need for RRT was lower in higher MAP group


PROWESS SHOCK •  Randomised, controlled, mulTcentre,

parallel group study

•  1,697 paTents with sepTc shock •  No difference in

–  28 day mortality (APC 26.4% vs 24.2%)

–  90 day mortality (34.1% vs 32.7%)

•  No subgroup effect seen in protein C deficient group

•  Serious bleeding n = 10 APC vs 8 placebo


B blockers in sepTc shock

•  Open label, single unit •  SepTc shock + HR ≥ 95 + NADR •  77 paTents – esmolol infusion (HR

80-‐94) vs 77 paTents standard treatment

•  Esmolol group –  28d Mortality 50% vs 81% in placebo

–  Improved SV index, LVSWI, lactate

–  Less NADR requirement

–  Less fluid requirement


Esmolol in refractory VF

•  Single centre, non randomised •  25 paTents with refractory (>3 defib

ayempts) VF or pulseless VT

•  Esmolol vs. placebo •  Primary outcome

–  Survival with good neurological recovery –  50% esmolol vs 11% control group

–  No difference in rates of ROSC or survival to hospital discharge


Steroids in Sepsis


The evidence…..let’s give it


8 trials published before ’89 -‐ No mortality benefit (some worse) -‐ Decreased Tme for shock resoluTon -‐ More secondary infecTons -‐ Higher doses and for shorter periods

19 ICU’s 300 paOents -‐ 50mg hydrocorTsone + fludrocorisone vs. placebo by 8hrs of onset of sepTc shock. -‐ ‘Non responders’ (adrenal suppression) beyer ICU (53% vs. 63%) and hospital mortality (61% vs. 72%). -‐ Increase secondary bacterial infecTons -‐ NNT = 7

(Annane JAMA 2002)

The evidence…..perhaps don’t give


CORTICUS

-‐ 52 ICU’s, 499 paTents

-‐ 50mg hydrocorTsone QDS vs. placebo 6/7 -‐ 28/7 mortality no different between groups and subset of non-‐ responders

Quicker shock resoluTon, catecholamine sparing, more secondary infecTons Sprung et al. NEJM 2008: 358; 111-‐24

-‐ Etomidate used in 1/5th of paTents -‐ Only 35% power to detect a 20% mortality reducTon -‐ High variability between laboratories in corTsol assays

Hang on….


Post hoc analysis of patients in VASST

Review of patients with noradrenaline (293) and steroids and vasopressin (295) and steroids 28 day mortality difference 44.7% versus 35.9% (p=0.03) ? Increased responsiveness to catecholamines ? Increased vasopressin levels ? Decreased inflammation Russell J, et al, InteracTon of vasopressin infusion, corTcosteroid treatment, and mortality of sepTc shock, Crit Care Med 2009 Vol. 37, 811-‐8

VANISH – second arm includes steroids. Eagerly await results

VASST


-‐ RCT 778 pts with sepTc shock

-‐  Noradrenaline vs. Norad & Vaso (0.03 units/min)

-‐  No mortality benefit

-‐  Higher doses associated with ischaemia

“Possible use if other vasopressors failed”

Less severe shock associated with reduced mortality when vasopressin used

Russell et al. NEJM 2008: 358: 877-‐87

VANISH


Vasopressin & corTcosteroids in SepTc Shock. A Pilot Study – Gordon A, 2014 HydrocorTsone

-‐ vasopressin sparing -‐ reduced duraTon vasopressin -‐ reduced dose vasopressin -‐ no effect on vasopressin levels

TRISS •  RCT 32 general ICUs in Scandinavia •  998 paTents with sepTc shock & Hb <9 •  Transfusion threshold <7 vs. <9 •  Excluded paTents with ACS •  Primary outcome:

–  No difference in death at 90 days •  Secondary outcomes: No difference in

•  VasoacTve drugs •  VenTlaTon •  RRT •  % of days alive & out of hospital •  Ischaemic events


OPTIMISE

•  RCT, mulTcentre, 17 UK ICUs

•  734 paTents

•  > 50y undergoing GI surgery with one or more ‘high risk’ risk factors

•  Algorithm-‐directed care dictaTng colloid and dopexamine administraTon using vs. clinician directed care without use of CO monitoring

•  Primary outcome: composite of 30d mortality and mod/major complicaTons –  IntervenTon: 36.6% –  Control arm: 43.4%

•  No SS difference in secondary outcomes –  POMS, infecTous complicaTons, criTcal care free days at 30d, mortality at 30d

and 180d, hospital LOS


IVOIRE Study

•  Randomised, open study

•  18 ICU’s in France, Belgium and Netherlands 2005-‐2010

•  140 pts with sepTc shock & AKI •  HVHF 70mls/kg/hr v 35mls/kg/hr •  Slow recruitment

•  No difference in mortality = 40% 28/7 •  HVHF not recommended


Fluids •  Don’t give too much

•  Don’t give too liyle •  Make sure you give the right

amount

•  Starches bad…very bad AssociaTon of HES administraTon with mortality and AKI in criTcally ill paTents requiring volume resuscitaTon. Meta-‐analysis. JAMA 2013 vol 309 (7)

•  Albumin back in? SAFE subgroup analysis 1200 pts with severe sepsis -‐ 28/7 mortality lower in albumin group (30% vs. 35% OR 0.87)

Finfer S et al 2011 Intensive Care Med 37:86–96 Delayney metaanalysis. Role of albumin as a resuscita>on fluid for pa>ents with sepsis. 17 studies, 1977 pa>ents. Crit Care Med 2011 Albios Study – GaXnoni (video ion ESICM website)


“lets talk about fluid responsiveness”

ESICM statement on colloids

1. Recommend not to use HES with mw ≥ 200kDa in paTents with severe sepsis or risk of AKI

2. Suggest avoid 6% HES or gelaTn in these groups

3. Recommend not to use colloids in paTents with head injury and not to administer gelaTns and HES in orhan donors

4. Suggest avoid hyperoncoTc soluTons for fluid resuscitaTon


ALBIOS

•  RCT, 100 ICUs in Italy

•  Aug 2008 – Feb 2012

•  1818 paTents with severe sepsis

•  300mls 20% HAS daily to maintain serum albumin at 30g/dl + CSL vs. CSL •  Primary outcome: mortality at 28d

–  HAS + CSL: 31.8% –  CSL: 32%

•  Secondary outcomes: 90 d mortality –  No difference


6S Study •  804 ICU pts with severe sepsis •  Compared fluid resuscitaTon

–  130/0.4 hydroxyethyl starch (tetraspan) vs Ringer's acetate

•  HES associated with –  Increased 90 day mortality

51% vs 43% –  Increased RRT requirement

22% vs 16%

–  Trend for increased bleeding 10% vs 6%


CHEST Study •  7000 ICU pts •  Fluid resuscitaTon with 6% HES

130/0.4 (Voluven) or 0.9% saline

•  No differences in – Mortality (HES 18% vs 17%) –  LOS – ICU / Hospital

•  HES associated with increased –  RRT (7% vs 5.8%; RR 1.21) –  Pruritus / Rash / HepaTc failure

-‐ Academic Department of Critical Care Queen Alexandra Hospital Portsmouth

CRISTAL Study •  2857 sequenTal ICU paTents

2003-‐2012 57 ICU’s

•  Colloids vs CSL for all fluid intervenTons other than maintenance

•  Colloids –  Reduced mortality at 28d & 90d

(25% vs 27% & 30% vs 34%)

–  More days alive without MV

–  More days alive without vasopressors

–  Less RRT

-‐


GastrointensTnal

Need a nice summary?


Open Access!#FOAMcc

CALORIES •  Open, mulTcentre, RCT

•  2400 paTents in 33 ICUs in UK •  PN vs. EN within 36 hours for 5/7 •  Primary outcome:

–  All cause mortality 33.1% (PN) vs. 34% (EN)

•  Secondary outcome: –  VomiTng more in EN

–  No difference on other 16 outcomes including ‘serious’ hypoglycaemia

–  NB daily calorific targets achieved in <40% in both groups


The SuDDICU study SDD

12 meta-‐analyses of 28 RCT’s. 10 show reduced pneumonia rate; 6 show morality benefit

•  Why have clinicians avoided implemenTng it in UK?

•  What are the barriers?

•  What further evidence is required before full scale clinical implementaTon


VITdAL-‐ICU •  RCT, Single Centre with 5 ICUs in

Austria, 475 paTents

•  Vit D or placebo •  Primary outcome:

–  Hospital LOS no different •  Secondary outcome. No difference:

–  ICU LOS

–  ICU-‐, 28d-‐ , hospital-‐ & 6 month-‐ mortality

•  Subgroup analysis –  If severe vit D def and given Vit D3 -‐> improvement in

28d-‐ hospital-‐ and 6 month-‐ mortality


SystemaTc review: CCM 2010 In those paTents receiving enteral nutriTon, stress ulcer prophylaxis may not be required and may actually increase VAP


H2R antagonists vs PPI

•  Cohort Study of 35,000 pts •  MV > 24 hours and either H2R antagonist or PPI

•  H2R antagonist group had –  Less GI haemorrhage 2.1 vs 5.9%

–  Pneumonia 27% vs 39%

–  C.Diff 2.2% vs 3.8%


Acute UGI Bleed

•  Randomised, parallel group study

•  921 pts with severe upper GI bleeding •  Compared restricTve (Hb <7g/dL) vs liberal

transfusion strategy (Hb<9g/dL)

•  RestricTve strategy associated with

–  Reduced number of pts receiving transfusion (15% vs 51%)

–  Increased probability survival (HR 0.55) –  Less rebleeding (10% vs 16%) –  Less adverse events (40% vs 48%)


Hepatology

•  ALD   Alcohol related illness costs NHS £1.7 billion/year

  SystemaTc review of 21 arTcles

  Overall ICU mortality 40-‐50%

  Mackle study only one to provide data on GI haemorrhage -‐ mortality 48%, 62%, 67%,68% for unit, hospital, 6/12 and one yr -‐ if get out of hospital most will survive

  Organ support -‐ 3 papers (venTlaTon, vasoacTve drugs, RRT)

  Mackle -‐

-‐  if MV and vasoacTve drugs hospital mortality 86%

-‐  If MV, vasoacTve drugs and RRT > 90%

-‐  If just MV 31%

  Saliba RRT 90%

  Rye 100% mortality if require RRT


Intraabdominal pressures

TRAUMA

PROPPR •  RCT in 12 N. American Level 1

trauma centres

•  680 paTents •  Transfusion of plasma:plts:PRBCs •  1:1:1 vs. 1:1:2 •  Primary outcome:

-‐  24 hour and 30d mortality no different

•  Secondary outcomes: No difference Time of haemostasis; Any of 23 pre-‐defined complicaTons; Hospital, venTlator & ICU free days

•  Post-‐ hoc analysis: -‐ Death by exasanguinaTon in 1st 24 hrs

much less in 1:1:1 group


PROPPR


TXA  CRASH -‐ 2 Lancet 2010

•  tranexamic acid in reducing transfusion requirements and death from significant haemorrhage following injury

•  20,000 paTents •  Risk of haemorrhage reduced by 0.8% •  No reducTon in transfusion usage •  Only 50% received blood and average only 3 (? ‘significant haemorrhage’)

 CRASH -‐ 2 subanalysis Lancet 2011 •  Mortality directly related to haemorrhage •  Tranexamic acid only effecTve if within first 3 hours. Beyond this Tme mortality increases


TXA  CRASH – 2 Does TXA reduce the risk of intracranial bleeding in paOents with TBI? BMJ 2011

•  250 of the 20,000 paTents eligible. •  Brain haemorrhage growth 5mm vs. 8mm (TXA vs. placebo) •  Not SS •  No menTon of extent of extracranial injuries in either group making mortality comparisons difficult

•  Not well matched as there were more pts with SAH (61% vs 43%)

•  No increase is focal cerebral ischaemia •  Conclusion “it is probable that benefits of tranexamic acid outweigh risks’


Trauma Haemorrhage

1. CoagulaTon monitoring and measures to support coagulaTon should be implemented early

2. Damage control surgery

3. Physiological targets, suggested use & dosing of fluids, blood products and TXA

4. PaTents on anTplatelet agents and/or oral anTcoagulants require special ayenTon

5. Mutlidisciplinary approach & evidence based protocols adapted to local circumstances need to be developed and implemented



•  Transfusion Triggers

•  Blood conservaTon •  Pre-‐transfusion clinical assessment •  Rate of transfusion/fluid balance •  InvesTgaTon adverse events •  Storage duraTon

Neuro-‐ICU

ICP Monitoring

•  MulTcentre RCT of 324 paTents Bolivia and Ecuador

•  Intraparenchymal ICP monitoring vs. clinical & imaging

•  No difference in mortality or neuropsycholoigcal status at 6/12


A Trial of Intracranial-‐Pressure Monitoring in TraumaTc Brain Injury Randall M. Chesnut et al N Engl J Med 2012; 367:2471-‐2481

Neuro


hyp://www.wessexics.com/WICS_Guidelines/

The SAH secTon definitely worth a read for the exam

CATIS

•  4,071 paTents •  Within 48 hrs ischaemic stroke

•  nonthrombolysed and ↑BP •  Hypertension therapy vs no BP Rx •  BP control effecTve •  No difference

–  death and major disability

•  14 days / hospital discharge •  3 months


INTERACT 2 •  2,839 pts with early spontaneous

intracerebral haemorrhage & ↑SBP

•  Compared SBP <140 mmHg vs <180 •  Aggressive BP control associated with

–  Trend for less adverse events (p=0.06)

–  Lower modified Rankin scores

•  No difference in mortality


Magnesium for aneurysmal SAH (MASH-‐2): a randomised placebo-‐controlled trial Mees S et al. 2012 The Lancet. Vol 380 9834:44-‐49

•  8 ICU’s in Europe and S America

•  1204 paTents

•  The quesTon: does Mg reduce poor outcome by reducing vasospasm and delayed cerebral ischaemia (DCI)

•  Magnesium 64mmol/day for 20/7 or placebo

•  Primary outcome of poor outcomes as defined by score 4-‐5 on modified Rankin Scale at 3/12, or death

•  NO DIFFERENCE


Delirium

HOPE ICU •  142 paTents with delirium

•  CAM-‐ICU assessment

•  Double blinded

•  Haloperidol vs. placebo •  No change in duraTon of delirium

in criTcally ill paTents

•  Haloperidol should be reserved for short term management on acute agitaTon

Effect of intravenous haloperidol on the duraOon of delirium and coma in criOcally ill paOents (Hope-‐ICU): a randomised, double-‐blind, placebo-‐controlled trial Valeirie Page. The Lancet Respiratory Medicine, Volume 1, Issue 7, Pages 515 -‐ 523, September 2013


TreaTng Delirium


101 MV paOents RCT haloperidol vs. ziprasidone vs placebo 21/7 study period No difference in any of the groups!

The beginning; Kress NEJM 2000 ReducTon in LOS

Girard Lancet 2008 Decreased ICU stay, Tme on venTlator and mortality

Strom Lancet 2010 ReducTon in LOS and venTlator days No sedaTon group -‐ boluses of morphine, well established in insTtuTon, more agitated delerium in no sedaTon group

Jacob JAMA 2012 PRODEX/MIDEX No beyer than midaz or propofol at maintaining light to mod sedaTon and more adverse effects. Increased paTent interacTons. Less vent days than midazolam

Ryker JAMA 2009 ReducTon in venTlator days and delirium

Mehta 2013 For MV paTents managed with protocolised sedaTon, the additon of daily sedaTon interrupTon did not reduce duraTon MV or ICU LOS

Don’t forget the simple things….


•  Small RCT 136 paTents

•  Used NEECHAM score •  Delirium (20%) similar but less mild confusion with ear plugs and good night sleep <50% vs. 25%

Guidelines for managing delirium



CCM 2013

FuncTonal disability 5 years azer ARDS

  109 survivors from ’98 -‐ ’01

  Interview, PFT’s, 6 min walk test, resTng & exercise oximetry, chest imaging, QOL survey

  PFT’s normalish

  BUT 6 min walk test 76% predicted, physical/psychological problems


Microbiology

•  96 ICU’s

•  Data from 60,000 admissions ’09-‐’11

•  Invasive fungal disease defined as BC or sample from normally sterile site showing yeast/mould cells in a microbiological or histopathological report

•  383 (0.6%) were admiyed with or developed IFD

•  Conclusion:

Incidence of IFD in non-‐neutropenic, criTcally ill paTents is low


5 steps to keep up with the literature afer the exam


1.  Sign up to criTcalcarereviews.com

2. Check out emlitofnote.com, The Boyom Line, LITFL & ScanCrit

3. Read N.Mays blog post ‘Drinking from the Firehose hyp://stemlynsblog.org/keeping-‐up-‐with-‐literature/

4. Get a twiyer account and follow #FOAMcc & #FOAMed hyp://www.wessexics.com/Wessex_ICM_Blog/files/5af570b612a8f22d6841f96179a2fc92-‐16.html

5. Podcasts – emcrit, RAGE, St.Emlyns, CRIT-‐IQ, PHARM, JICScast, FOAMcast to start, CriTcal Care PracTToner, HEFT EMCAST


& Book your place at #smaccUS & ICSSOA2015


Best of Luck!

www.wessexics.com

@WessexICS @WICSBoyomLine

@stevemathieu75

PINCER - Hot Topics

Health & Medicine

Transcript of PINCER - Hot Topics