Intensive Care: it's a risky business. 2014 CICM ASM, Brisbane

Rajesh Krishnan on 13-06-2014

Crit-IQ blog
It's that time again the ASM is upon us. There is a tangible level of excitement in the room as colleagues greet, mixed with the obligatory coffee fumes!

Day 1. Session 1
After a gracious introduction to proceedings. Dr Allan Goldman from GOSH is the first talker. Introducing the theme of risky business and the possible key messages that intensive care can take from other industries, the 2005 London bombing police response and the NASA shuttle accidents being discussed examples.

Dr Goldman describes Intuition versus analytic reasoning as the dual process for individual decision making, the process of response to disaster and the key considerations for analysing this.

The next speaker is Prof Brian Cuthbertson. We are given a personal insight into reflections on the Cuthbertson-Rasouli case. First we are given an introduction to differing healthcare legislation of Australia, United Kingdom and Canada. Next its a journey through the maze of legislation and frankly bizarre decisions that have been concluded; issues such as the need for consent for palliative, consent to withhold beginning or stop CPR.

Prof Cuthbertson ends suggesting beneficence is a medical construct and medical paternalism is dead. He Suggests a future practice for us including the need for a treatment plan a-priori and obviously clear documentation.

The final speaker of session 1 is Prof Anderson Perner. It's the good, the reasonable and the ugly of starches combined with the risk of offending product manufacturers. Of course discussing the 6S trial. The robustness of the trial construct is first reiterated. Interesting to hear the initial thoughts from manufacturers including that the 6S trial had used a potato based starch (0.42) as found in Tetrapen instead of a corn based starch (0.40) as found in Voluven and their initial kind approach suggesting alteration to the article, followed swiftly by letters threatening legal action based on inaccurate data. The backlash from producing data that threatens a large economically successful company is not unexpected. Fortunately for Prof Perner subsequent data such as that from the CHEST trial reinforced the findings of 6S, the rest is now history.



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J Doyle wrote 06-13-2014 03:04:43 pm
Session 2

Another coffee. A play in trade hall with the latest in medical equipment, it would appear an ipad on a stick is the way forward in design for ventilators, RRT or anything else really, in fairness it is very intuitive... I just worry that my 6 year old might be better able to navigate the functions than I.

Day 1. Session 2
Associate professor Stephin Bolsin opens proceedings. A lesson in history on the Bristol peadiatric heart surgery scandal and the dawn of clinical governance as we now know it. The professional dilemma of working within an institute, gathering data and the politics of raising the issues found both amongst colleagues and to the legislative boards was clearly a daunting task. However a 7 year period of failure to act did result in preventable paediatric deaths

The fallout of this has resulted in a number of procedures that deals with clinical issues with a more robust mechanism. For example the privy council upheld that doctors that are managers do have a responsibility to uphold patient safety. The need for performance review and revalidation procedures. The introduction of mandatory reporting.

The next speakers is Professor Gerry Fitzgerald. Starting by stating that the mitigation of risk is everyone's responsibility. All are accountable, the day of the senior all knowing doctor without challenge is gone.

A nice reminder of the Swiss cheese model is compounded by the concept of lining up more layers of cheese rather than a more robust process. So what do we accept, well ultimately the level of standard is like a bell curve, yes there is the best but also the mean average, this raises the issue of reasonable competence versus the best. In reality the key as to what to accept depends on what is being assessed to take an aviation example (the first of the conference so far) airport coffee quality is not as important than safe take off and landing.

Courageous conversations are difficult when confronting a colleague about there performance. Few activities are more time and energy sapping. However it is a necessary requirement for mitigation of the risk of an underperforming colleague.

Finally in session 2 it is time for a hypothetical. Run with a panel based discussion Drs Bolsin, Fitzgerald, Wenck, Stewart, Freebairn, Semark and moderated by Dr Parr. The situation; you arrive to a new job as a day 1 intensivist to find that the acting director has left and you are now it! The first point is to note that this scenario is not foreign and actually represents the experience of some of the panel. The second point is how foreign much of the administrative role, particularly budget review, may be.

Some great tips and tricks were mentioned:
- The budget - an argument to benchmark funding against other units. The general consensus is that simply asking for more cash won't work.
- A training, accredited unit, enables one to use the college outline as a process for budget review.
- ACHS accreditation, try not to cram policies before the event. Instead use it as an excuse for a business case for research staff etc. the consensus though is that this is easier to say than do!
- Adhering to practice standards are essential, the example of 1:1 nurse:vent patient being the example used. Adhere but you may need to get there slowly without treading on feet and with staffing constraints attended to.
- Those clinical issues which one can deal with (the example discussed being catheter related blood stream infection) should be dealt with aggressively
- Data can be misinforming..... Look into it!

J Doyle wrote 06-13-2014 03:21:43 pm
Session 3

Post prandial now. Always a tough session to keep your audience's undivided attention. However I can tell you that the 5 presenters giving poster presentations had us engaged throughout. Some interesting research is going on out there. The use of ECHO speckling versus angle independent M-mode with echo as a measure of diaphragm contraction. The consideration of cerebral tissue sats in cyanosis cardiopathy and a possible predictive value with NIRS. To mention just a couple.

J Doyle wrote 06-13-2014 03:35:07 pm
Session 4

Coffee tick.

Dr. Johnny Miller starts of session 4 with paediatric syndromes graduating to the adult ICU. A topic that will affect all intensivists no matter which unit you may work in. The reason that this is a problem, children are now surviving illnesses which previously they would not have!

A demonstration of the PICU falling mortality reveals a current Australasian mortality rate of 2.7%. Not all great news though, there is an increasing level of PICU discharges with severe disability.

What of those PICU admissions with syndromes, well 99% of admissions are not directly related to their syndrome. I.e. It is for an inter current illness or for support after surgical intervention.

As far as the adults go. Well there are now more adults than children with severe congenital heart diseases. That doesn't include the incidence of lost to follow up and the poor transition from paediatric to adult services. The figures for adults with CHD do suggest longer length of stay and complication rates. Most likely due to the underlying poorer physiological reserve.

To finish there are some great outcomes, not least is the amazing long term survival rates of Fontan surgery.

The next speaker is Dr Andrew Udy who is talking on the complexities of adjusting drug doses in critical illness. So why perform dose adjustment? Well Dr Udy lists the benefits to the individual patient and then the population as a whole, notably with regard to antimicrobials.

Use of some common examples include everything from warfarin dose adjustment to ARDSnet ventilator protocols.

How to do it.... It's back to PK-PD principles and interacting interventions. The clinical consequences of not getting this right include those of over and under dosage.

Next up is Dr Michael Reade talking on the evidence for daily sedation breaks. Discussing first the Kress paper of 2000 in the NEJM, then the awakening and breathing controlled trial by Girard in 2008 in the Lancet, next the Mehta trial in JAMA in 2012. All essential reading for trainees (check out our journal club). Findings demonstrate an improved mortality and reduced length of mechanical ventilation and yes there were more self extubations (although unsurprisingly few of these required reintubation)

So what about effects on TBI. Well sedative reduces brain metabolism and so mitigates reduced oxygen delivery, sedatives protect against seizures (in theory) and sedatives may be directly neuroprotective. However on the flip side animal data suggests high dose sedatives suggests impaired brain injury repair. Also sedatives reduce MAP and therefore CPP (easy enough to counter with vasopressors). Finally the ongoing issue of ICP monitors in theory to help avoid the masking of neurological deterioration by sedation.

The final speaker is Dr Adrian Mattke who discusses high risk clinical scenarios in paediatric intensive care. Starting with the shocked neonate Adrian suggests a differential diagnosis and practical management approach to what for many would be an alarming case.

Next it's the blue neonate. Some interesting points on the difficulty of intubating a patient with potential cyanotic heart lesion. Also, and this is a point of difference to adult medicine, Noradrenalin is never the first agent of choice, instead use of dopamine (maybe) or dobutamine.

The differences in management of DKA is discussed next. Finally Dr Mattke demonstrates the ease of vascular access in neonates with a finesse that only someone with considerable experience could do and make look easy.

J Doyle wrote 06-13-2014 05:20:13 pm
Crit-IQ blog. Session 5

The ASM is clearly in full swing now. The trade hall was in such a buzz with so many people catching up, I missed out on my coffee.

Session 5 begins with Dr Allan Goldman who discusses reducing risk after hours. Whilst numbers of staff may be difficult to alter the use of IT, when appropriately incorporated, helps. The emphasis of the talk is on teamwork, in particular the difficulties in effectively using theses large multidisciplinary teams.

One method of creating resilience includes high fidelity simulation training, the use of regular M&M and real time data analysis.

So what's next. Resident consultants? ICU outreach? Data trends and early warning systems? High fidelity simulation? Sophisticated IT dashboards? To be discussed...

The next speaker is Professor Nicholas Graves who talks about the cost effectiveness argument for decision makers.

Prof Graves demonstrates by way of a simple graphic the correlation between cost and QALY. It seems that a cost of $47000 per QALY is our cut off after international research into peoples personal preparedness to spend money for a quality life year.

An interesting point is made on the quality of design types that generate effective data. Hypothesis testing maybe irrelevant for real world decision making. So to be an efficient health services there is a need to take cost effectiveness seriously.

Our final speaker of the day is Dr Duncan Young. Who's talk entitled offloading risk? The responsibilities of a DMC in an international RCT. Dr Duncan gives an insight into the role of data monitoring committee, an independent group that as he states 'helps you, in a trial, do your job better'. They are advisory and report to the training steering committee primarily on safety issues.

We have explained to us possible reasons for early termination of a trial eg stop due to harm, or stop once there is proven benefit but ongoing study is not cost effective.

A summary of the DMC involvement and their suggestions during the trial setup for CHEST on the background of a meta analysis and the need to repeat it with exclusion of the Boldt literature. The DMC resulted in requesting increased reporting on acute kidney injury and CHEST went ahead.

Also commented on is the DMC involvement in the NICE-SUGAR trial

Now the AGM.

Well that's it for day 1, as we file out of the spectacular venue that is the Brisbane convention and exhibition centre I am alarmed to find an absence of the coffee cart, however the welcome reception is upon us with an open bar...... Until tomorrow then.

J Doyle wrote 06-14-2014 07:03:59 pm
Taking the blog today is Dr Sacha Richardson

Session 10
Starting the blogathon session from here at the CICM ASM...

John Fraser - "When should I transfer a patient for ECMO? (...Ever??)". John starts by giving a brief summery of ECMO evolution from the 1970s, detailing many of the issues with biocompatability. The CESAR trial (90 patients transferred for ECMO Vs 90 patients conventional treatment) showing better outcome with ECMO. But was some of the benefit derived from being in a specialist unit. Some more recent data from the H1N1 outbreak suggests equipoise between ECMO and conventional Rx.

John notes that there is a diminishing incidence of ARDS in Australasia which is reducing the pool of patients requiring ECMO.

The rationale for ECMO retrieval - patients are usually unstable and at risk of deterioration during the transfer. Better to send a specialist retrieval team and place the patient on ECMO for the transfer. Currently Qld doesn't have a service fully set up, so much of the data shown is from the NSW group.

John notes the white out of the lungs seen within a few hours of putting the patient on ECMO. There is activation of an inflammatory cascade which actually worsens the lung function. Fentanyl is cleared much more quickly in the ECMO circuit, morphine levels seem to be better maintained. Probably the drugs are getting sequestered in the circuit. There are likely to be many differences in drug pharmacokinetics.

Improved safety in the last 10 years of transfer of ECMO patients. Key items, logistics, equipment, team. ECMO checklist.

New indication for ECMO - Septic Shock, especially for paediatric population. Trauma is an undeveloped area.

A great photo of a patient walking on ECMO! Though John admits not one of his patients, but he hopes to have one in the not to distant future.

ELSO guidelines for ECMO transfer are worth a read.

Next up... Anthony Holley - RBWH intensivist "The Risks of Anti-fibrinolytics or Pro-coagulants in major bleeding". A gruesome trauma photo from Afghanistan. Interestingly most major trauma patients had PEs within 8 hrs. >25% of severe trauma patients arrive at hospital with established coagulopathy. Incidence of DVT in major trauma is 1.5-5%. 11-44% in higher risk groups. 3% risk of PE with a 50% mortality. A brief review of the coagulation cascade. Broadly a balance of clot formation and clot breakdown.

The coagulopathy of trauma: too little, too late (article published by Antony).

A ratio of blood products 1:1:1 - seems to have better outcomes. PRBC older than 21 days are more likely to give you a DVT. Fresh red cells are better! Some data to suggest platelet transfusions increase your DVT risk, although it was derived from non-trauma, non-obstetric, non-orthopaedic population.

How about clotting factor concentrates? Maybe these will supersede FFP in the future.

Activated factor VII - data not there for survival benefit. It seems to increase your risk of arterial thromboembolism.

Tranexamic Acid - Data from 10,000 patient trial for trauma patients showed a mortality benefit. Can it also cause less thrombosis? There seem to be a biological case for this as well. Use it within 3hrs of trauma.

Low fibrinogen is a predictor of mortality. Aim for levels >1.0 in trauma.

Use of TEG in trauma too.

Prothrombinex also now recommended in Europe for bleeding.

Porcine model for prothrombinex (grade III liver laceration), higher doses reduced DIC. However increased risk of thrombosis.

Antony raises the question: what is the risk of thrombosis with a combination of these agents.

TXA is probably safe. Transfusion poses a risk. aVII poses a risk. PCC probably poses a risk. Risk / benefit needs to be carefully considered. Beware combination strategies. Don't be afraid of using thromboprophylaxsis in these patients.

Craig French... Blood transfusion in the critically ill. Anaemia is bad for you, especially in ACS / Heart failure / CRF. If we correct it with PRBC is it good for you? Risks: Infections, TRALI, fluid overload, immunomodulation, allergic reactions. Benefit - improved O2 delivery to the tissues. And makes you cycle faster it would seem.

What are the actual risks (bearing in mind that risk is subjective). HIV/HCV/Malaria <1 in 1million. Bacterial infection 1 in 500,000. HBV 1 in 540,000. Frequency of serious transfusion event: 1:2268 PRBC (probably under-reporting). What are these events: Allergy mild to full blown anaphylaxis.

Immunomodulation: TRALI - 1 in 1200 to 100,000. TACO (transfusion associated circulatory overload) .

Efficacy (RBC Vs no transfusion - observational / cohort data) or liberal Vs restrictive transfusion strategies. Marik 2008 - 293,000 patients - demonstrated independent OR 1.69 of increased mortality with RBC transfusion. However, that risk almost disappears if the data is analysed differently statistically.

Two RCTs liberal Vs restrictive. Potential benefit to restrictive (non significant). Paediatric patients - no difference in MODS.

Now >50 papers demonstrate risk of transfusion. No evidence for liberal transfusion. Restricted is better 70-90. But what about ACS. TRIC study 2001. FOCUS study - hip fractures. Liberal Vs restrictive - no difference between groups. MINT pilot - symptomatic IHD - suggests liberal is best. BUT the CRIT pilot showed the exact opposite!

An excellent summary of transfusion.

Simon Erickson - Paediatric Sedation. Simon starts off with a case discussion based on a 5 yr old ventilated patient on inotropes and high FiO2. Little evidence to support guidelines / protocols. Delirium and Long-term cognitive effects remain unknown. 50% adverse event rate noted in recent trials. 70% of units in the UK use restraints in paediatric population. Many drugs used are not TGA approved for children. Metabolism is variable. Scoring systems - State Behavioural Scale and Comfort B. Difficult to assess children. Many over sedated, more so than under sedated. Sometimes target deep sedation - ICP and Pulm HTN, however associated with adverse events.

Propofol infusion syndrome (PRIS). Metabolic acidosis, rhabdo. >50% mortality. First reported 1992 from UK. Associated with young age, high dose >5mg/kg/hr, prolonged use >48hr.

Midazolam - GABA agonist. accumulation.

Ketamine - limited metabolism in newborn. Emergence phenomena

Dexmedetomidine - Not TGA approved. Increased metabolism in 3-10 yrs old (need 130% of adult dose), bradycardia, hypotension.

Narcotics - associated with poor verbal and visual function after PICU.

Known unknowns: Tolerance - occurs in upto 60 % of critically ill children. pharmakodynamic phenomena but not well defined. Withdrawal syndromes 17-35%. Delirium 50% incidence in adult, unclear in children - 10-15% possibly. Difficult to assess, especially in younger patients.

Midazolam and Ketamine use increases apoptosis of neurones in animal models.

Baby SPICE - looking at existing sedation strategies across PICUs. No synchonry across units. Morphine and Midazolam most commonly used. Depth of sedation associated with longer ventilation and longer PICU stays.

Risks - adverse effects, safety, off label use,

Now time for a coffee. And bit of cake.

Session 11:

An entertaining session now - a debate.
Rinaldo Bellomo "The risk of becoming an intensivist: Just say NO!"

Rinaldo is proposing that the future of ICU is uncertain. Expensive in a time of cost restraints. No jobs with increasing numbers of fellows piled up with no consultant posts. ICU Fellow unemployment rate 6.8%. 20% of fellows do not do any ICU at all. There will be a growth of about 20-30 positions per year. However we are training 60 or so trainees per year. ICU carries no clout. It has little or no profile with the public. Dependent on surgical patients. You are a prisoner to the hospital system - the administrators. Much like being a prisoner in Guantanamo! It's a buyers market. Private hospitals are clamping down on ICU costs.

CICM has not adjusted training positions, unlike the other colleges (surgeon, dermatologists). Why is this so? Ideology / Financial / Desire to have hundreds of fellows to do the night cover? Jobs are reducing in ED and Anaesthetics, now with RACP non allowance of dual training limits, there is an evaporating option B. It's a Ponzi scheme. Shift work - will become the norm for intensivists. We will become like interns again! Rinaldo suggests get out now, whilst you can. The train has left, the tracks are being pulled up. Rinaldo suggests something akin to the French Revolution!

In retort - Ross Freebairn... Become an intenstivist! This is a great speciality. No clinics. Procedures. Intellectually challenging. Why should there be any doubts? Ross suggests that perhaps the reason the sepsis survival rates are increasing is because of an increased number of critical care specialists.

Will Fellowship guarantee a job? - well no. No entitlement of a job, this has always been so. However, increasing well recognised training internationally. There will be a shortage worldwide. Especially in the US. The MET and outreach teams "ICU sans frontiere"! The hospital overnight urine monitor. It is possible to have a family life, unlike cardiothoracics! Longevity - Bob Wright and Ted Ward have survived into their 70s in the specialty. Factors frequently cited as a cause for reducing ICU hours, call backs, night hours. Intensive care 10 years on - obesity crisis. Ross ends with some footage of the All Blacks giving the Aussies a bit of a pasting.

Questions: Gender imbalance. 80% of intensivists are males. 60% trainees are males. Whereas 60% of medical students are women. The panel suggests perhaps some gender reassignment surgery could be offered to the board to redress the numbers.

An interesting and passionate debate!

Now Dr Allan Goldman, from Great Ormond Street Hospital.

Part 1 - "A cluster of failures". Prof de La Val - cluster of failures of switch operations after he had done 50 with no issues. James Reason was asked to investigate with a view to human factors. They looked at F1 teams and pit-stops. Realising their handover from OT to ICU staff was chaotic, non-standardised. Transfer sheet with vent settings, inotropes sent in 20 mins prior to arrival. Technology handover (equipment), then information handover (Anaesthetist then Surgeon), finally discussion and plan. The switch program continued with a 1% mortality rate. The track their near-misses and aim to minimise risk.

Part 2 - "When everyone goes home!". 200 Consultants / 80 Registrars / 215 nurses in the day goes to 0 consultants / 4 registrars / 90 nurses at night. Aim to improve the "radar" and handover. They looked at Heathrow airport air traffic control to identify better handover processes. They also looked at foreign exchange handover across time zones. GOS ICU introduced formal handover teaching, identify "flagged" patients and formalised the evening handover.

They looked at how good the radar was - 83% of patients who deteriorated overnight had been flagged when they looked back at over 1500 patients. But still a gap. Different specialties had differing interpretations of which patients needed to be flagged.

And now a further debate "risks of having too many or too few ICU beds". Michael O'Leary kicks off. He identifies the variation of ICU bed definition from country to country. Also large variation in ICU bed to population variation (Australia circ 10, USA circ 16 per 100,000 population). The consequence of too many ICU beds. 1 in 5 Americans die in an ICU. 1 in 20 do so in the UK (6.6 ICU beds per 100,000). Looking at patient wishes, only 7% want to die in hospital, and 70% would like medications to make them more comfortable rather than life prolonging treatment. Further consequences - increased interventions.
If we have too many beds, we run the risk of losing the closed ICU paradigm . Bed oversupply makes refusal of admission difficult or pointless. Manpower and workforce issues. Professional dissatisfaction - dumbing down of the intensivist.
We have a responsibility to ensure appropriate availability and usage of resources. Avoid empire building. ICU should be restricted to those with a likelihood to derive true benefit.

On the other side of the debate - Michael Reade. The risks of having too few beds. 39% increase in ICU beds in the past 15years. Some of us have forgotten what it was like having too few beds. Bed days are increasing faster than beds (more patients having shorter stays). However, there are coping strategies for managing too few beds, which ultimately have worse prognosis for patients. Interhospital transfer increases mortality OR 1.3. Some evidence if there are no ICU beds, then patients are more likely to get palliated on the ward. If there is also a delay to arrival to the ICU, this is associated with an increased mortality. Another issue is too few beds leads to loss of experience and currency with managing diseases leading to a reduction in performance. Too few beds also leads to inefficient elective surgery due to cancellations. Early ICU discharges can lead to increased readmissions, lengthened hospital stays. Medico-legal risks. Conflict with other specialists - we have to talk directly with out colleagues to deny them ICU beds for their patients.

Suggestions of how to deal with imbalance between supply and demand. Set rules about what can and can not be admitted to the ICU. For example in Afghanistan in coalition field hospitals there were rules of what could be admitted to the ICU (for eg Penetrating HI with GCS <8 in a local Afghani - for comfort measures only, similarly >50% TBSA burns). Very different to civilian care. In such a system it removes clinicians from the conflicted roles of patient advocate and gatekeeper. Reduces heterogeneity (post code lottery).

J Doyle wrote 06-15-2014 11:51:28 am
Today both James & Sacha join forces to bring you the final days events

Session 11 Sunday morning

Trainee Breakfast Meeting.

Reasonable turn out. The coffee is going down well after the dinner last night!

Rob Bevan is chairing a session on getting international fellowship with the international speakers plugging their units / countries to the attendant trainees.

Professor Brian Cuthbertson shows a video detailing Sunnybrook Hospital Toronto including interviews with international fellows. Trainee Visas can be easily attained for Canada and their admin dept will help with all the paperwork. A busy 52 bed dept, with good exposure, especially to trauma. And Toronto is a great city too!

Next up Prof Michael Reade. He has spent some time in the USA (Pittsburgh) in the mid naughties. He describes it as intensive, but in retrospect, very formative for his career, especially in research. He was able to do a lot of echo and was paid to do the Masters in Public health. He suggests working out if you can apply to be a junior attending. 80 hour week. 5am starts. Maybe one day off a week. Standard $50k / yr... which you can live on in Pittsburgh, but probably not in Boston - if you go there you may need to draw on savings. Two subdivisions: Pulmonary CCM or Multidisciplinary CCM. He recommends having an Australian mentor to keep an eye on you. Try for an E3 visa (use the hospital's legal team once you have a job lined up). Board Certification is impossible without US residency. Understand that US physicians are not interested in how things are done in Australia, you've come to the US to learn how to do medicine properly!

UK - Duncan Young
UK are short of ICU trainees. Especially in the larger teaching hospitals at the senior trainee levels (ST6/7 or fellow). Most don't care about base specialty / ICU specific training. Australasian ICU training is held in high regard. Pay scale $107k -$125k. Preferably after attaining Fellowship exam.

Visas: Assuming you don't have British citizenship... requires a tier 5 visa via the MTI (Medical training initiative) which requires the Royal College of Anaesthetists and Academy of Medical Colleges. Tier 2 visas can be used, but only if you can't find anyone closer to home (UK or EU workers first).

Timeline: Oxford like to arrange posts at least 1 year in advance.

Oxford has bowel / kidney / pancreas transplants. Trauma: The Royal London or Royal Free.

More info:

Rob asks the panel how long realistically should you start planning / contracting the hospitals. Minimum 1 year they all say, even out to 2 years in advance.

For the UK you may have to do an English exam (even if you speak English!).

Rob Bevan does a quick session on CICM trainee committee and says they're looking for QLD and SA representatives. He also details some suggestions that the college is working up to improve the trainee experience.

Session 11:
Coffee being drunk by the gallon. And now back in for the next session.

Luregn Schlapbach (great name) - is talking about understanding the risks - genomics of severe infections in PICU patients.

In PICU the risk of death from severe sepsis is about 20%, and whilst there has been a slight improvement in survival over the past 10 years, it has not been as significant as that seen in the recent adult data.

21% of childhood deaths are infection related. 50% have no underlying disease. Decreasing incidence of sepsis with age. Prematurity is a major risk factor: 24-28 weekers have the highest incidence.

Why do some children get very sick with meningococcus. Are there host factors at work? ... any severe infectious illness needs to be considered as a manifestation of an immunological deficit.

Luregn does a quick recap of innate and adaptive immunity. Genetic influences from twin studies. Up to a 10 fold increase in risk of dying from severe sepsis if an identical twin has died from sepsis.

Mendelian susceptibility: IRAK-4 deficiency identified in a French family with high incidence of childhood mortality from bacterial infections. However if they survived to age 8, then their risk of infections reduced dramatically.

But are there SNP (single nucleotide polymorphisms) that are associated with increased risk of severe sepsis. MBL deficiency is more frequently seen in children with meningococcal disease.

Can the risk of death be split into to camps: 1 Infection susceptibility. 2. Multi-organ susceptibility.

Most of the SNP work has not yet derived any clinically useful data.

Genome Wide Association Studies (GWAS). CFH region on chromosome 1 associated with host susceptibility for meningococcal disease. European study identified this by looking at several hundred meningococcal disease children and compared them to controls. It has been repeated in other European countries with similar results.

We continue with Dr Duncan Young who discusses the ICU follow up clinic that he has bee involved in for the last 10years. Dr Young gives some disturbing statistics, notably the 7% mortality rate amongst those patients discharged from ICU with curative intent. Requirements for f/u clinic - ICU stay>3 days, in catchment area, flagged for clinic at 3 months, survival check (electronic), 3-6 patients / clinic.

There are some clear benefits to outpatient follow up, not least is the ability to realign those patients lost to the system for their specialist follow ups.

At the 3 month follow up the condition seen in the clinic -
Airway; Post-intubation tracheal stenosis (PITS), critical-PITS if >30% loss of circumference, although theses rarely need intervention, hoarse voice and cosmetic tracheostomy scar complaints.

Neuropathy; very common both those related to surgery and peripheral sensory neuropathy, meraga parasthetica (neuropathy of lateral cutaneous nerve supply), radial nerve supply (cutaneous branch occurs in 1 in 10 patients).

Incisional hernias; most likely related to poor wound healing amongst critically ill patients

Hallucinations; generally towards the end of the ICU stay, and notably to the patient these seem very real and are often persecutory. With this in mind Dr Young is able to draw the similarities between amnesty international definition of torture and routine ICU care... Occasionally can be related to real interventions / environment. "at sea" - ripple mattress. "seeing the dead" - relatives at the end of the bed. "being gassed by the tube in my nose" - NGT. : Intensive Care: Patient's experiences. Really good resource. Worth taking a look at patient experiences.

PTSD: 5-64% have symptoms. Not formally diagnosed as per DSM V. Normally the symptoms settle over 6 months. However Duncan refers about 2 per year for CBT with a clinical psychologist.

Next up is Dr Adam Deane with a discussion of who's in charge? It would seem not the clinician. Adam touches on the considerable risk of market driven training and notes the college currently has more trainees than fellows. Adam mentions about 79 FTE positions may be funded in the next 5 years for over 300 current advanced trainees. There is a risk of a climate of underemployment. As a result novel solutions may occur such as rapid response and out reach teams. There is substantive risk to the public/private ICU practitioner with the emergence of 24 hour cover.

So what can we do, well perhaps rationalise training numbers to reflect the potential job opportunities, focus on intensive care medicine, avoid specialised ICUs, maintain belief in closed ICUs. The greatest risk is to do nothing at all.

Well question time reveals that this issue is at the forefront of the minds of many clinicians. A considerable few point out the counter argument even suggesting that the deregulation of university fees and the reduction in part 1 exam exemption may see a shortage of intensivists!

J Doyle wrote 06-15-2014 12:48:00 pm
Session 12

Duncan Young - ARDS

The Berlin definition of ARDS.
Mild / Moderate / Severe. Debates the usefulness of this definition.
Duncan suggests ARDS (Absence of a Real DiagnosiS).

Only 16% of ARDS mortality is from hypoxic respiratory failure.

ECMO and standard care die at similar rates (obviously can't be hypoxic if on ECMO). What are the targets of therapy? Try and avoid iatrogenic injury. ARDSnet data - Low Vt strategies / permissive hypercapneoa.

Prone ventilation. Mortality reduction of 11-16%. NNT 6-9. But Duncan remains a little sceptical of the size of the benefit.

Ideology / theory of oscillator ventilation is covered next. Oscillate (Canada) result - stopped early for harm in the treatment group NNH 10. Oscar (UK) - Equipoise. Why the difference? The oscillate control group seems to fair better than the Oscar group.

Oscar control mean Vt 8.3 Vs Oscillate 6.1... could this explain it?

Why did Oscillate HFOV arm show harm... 78% were on vasoactives Vs 58% in control (45% for both groups in Oscar)... could there be some cardiovascular cause.

ECMO - A brief history. Zapol et al 1979 - showed equivalence with standard care. CESAR - is actually a study on a package of care (transfer +/- ECMO in a specialist unit Vs conventional Rx)... but it does show ECMO benefit.

Flu pandemics have changed things - they have a propensity to become very hypoxaemic and ECMO can save them.

Ultra protective lung ventilation: How about low Tv ventilation, with Extra-coporeal CO2 removal... there have been a couple of studies which showed no benefit. But new studies coming through. Newer technologies have been developed from Novolung - now centrifugal pumped membrane CO2 removal.

Future trials - we need a lung damage marker - "a troponin for the lung", this would allow smaller trials as you're not looking for a mortality benefit. Diagnosis-specific trials. It is difficult to recruit for the ARDS studies because the incidence of ARDS is reducing.

Brian Cuthbertson up again:
Tolerable Risk - Why are countries so different and what does it mean for clinical studies.

Factors that affect perception of risk. What is at stake, what are the odds, what are the consequences.

Less ICU beds = sicker patients. Therefore UK has higher mortality in ICU. Stressed ICUs have worse outcomes. Discharges out of hours have worse outcomes.

The rule of rescue - says you are prepared to spend disproportionate sums of money and time to save one life, even if the resources could be better allocated.

First RCT 1948 - streptomycin for TB.

How to manipulate the size of a trial. Delta inflation (absolute reduction eg mortality). Pressure to delta inflate to reduce size of trials... however then trials are stopped early for futility. Really we should be looking for trials with delta sizes of 3-7%.

Risk of stopping trials early for benefit when the recruitment size is still small - risk of being an outlier.

NICE-sugar - by sticking it out and proving that 78 lives were lost in the treatment arm they have given us clinically useful research.

Risk of too many exclusions. Non-representive of general ICU.

Conclusions: we all meet risks in our practice. We need to identify and mitigate risk in our research.

Lastly! A Debate... Session 12. "The Medical Emergency Team should be the hospital's solution for its increasingly risky practice"

For: Imogen Mitchell, John Santamaria, Daryl Jones.
Against: Ray Raper, Marianne Kirrane, Shane Townsend.

Minimising risk: Most effective is remove the patient! Sadly not helpful. 2. Guard the patient. 3. Further training for junior staff / ward nurses.

Now Shane Townsend against: The high priests of MET teams insist there is no need for evidence for their benefit. Currently no evidence it reduces hospital mortality. 75% of MET calls were handed back to the home medical or surgical teams. Most studies are before and after single centre designs. More NFR orders are placed after MET team deployments. None have been randomised, none had a concurrent control group, none were blinded. 1 attempted to adjust for secular trends. Perhaps the MET system should be renamed. The DUMP team - Delegated, Under-resourced, Medical, Palliation team.

For: John Santamaria... Argues that it takes time for the MET teams to become established before you can see a mortality benefit, perhaps why some of the research hasn't shown benefit. MET teams get intensivists out of the ICU. Improves relations with other specialties, gives an opportunity to educate and improve performance on the general wards.

Against: Marianne Kirrane. Single RCT wasn't helpful. Are intensivists really the best people to be managing the MET team? Only the intensivists think so. Perhaps the Nurse Unit Managers are better placed. This is a service that is "free" to the hospital... but that obviously isn't so. No one has done a cost benefit study... with no evidence of benefit.

Daryl Jones: Increasing gap between what juniors can do and what they may be able to do. Can use the MET patients to swap out bed-block patients in the ICU. 1 in 4 hit rate in terms of MET patients getting admitted to the ICU. What are the other options? Train all Junior medical officers to the required ICU standard - not practicable. Increase the ICU to 100bed unit... Allow the juniors to do all the end of life planning - with predictable consequences.

Against: Ray Raper. No evidence to rebut! Causality is difficult to prove. Some studies that show a benefit seem incredulous. Beyond reasonable. Is it harmful? Concerned about abdication of responsibility of subspecialties for their patients. "It's OK, the MET team can take care of it!". Concerns about the residents leaving the ICU - missing out on training in the unit, and performing unsupervised work on the wards. 90% of patients who die in hospital have DNAR. How much more can the MET team do about that last 10%, given that we work in hospitals not hospices. Surely the home team is best placed to discuss end of life care, not a "blow-in" from the ICU in the form of the MET team.

Finally the vote - well there is no need to count with less than 5 people in the auditorium voting for the MET team, perhaps this reflects personal experience and not the quality of presentation.

To finish a mark your diary announcement - it's the May 2015 CICM ASM in Darwin, Northern Territory. The theme next year - Catch the Bug: Battling Infectious Diseases in ICU.

Thanks for joining us on the Crit-IQ blog. If you were there what was you highlight? Post your comments below.




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