PINCER - Hot Topics
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These slides form part of a Hot Topics presentation from Feb 2015 for Portsmouth INtensive Care Exam Revision (PINCER) Course
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PINCER - Hot Topics
- 1. 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
- 2. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 3. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 4. RecommendaTons Capnography Airway equipment Back up planning Staffing PaTent transfers EducaTon/training Tracheostomy tube design Team working Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 5. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 6. ARDS
- 7. 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% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 8. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 9. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 10. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 11. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 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
- 12. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 13. PROSEVA Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 14. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 15. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 16. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 17. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 18. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 19. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 20. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 21. VAP Academic Department of Critical Care Queen Alexandra Hospital Portsmouth What is VAP? What are the common organisms (early vs. late? Scoring systems e.g. CPIS, HELICS What anTbioTcs would you use? How can you reduce incidence Open Access! #FOAMcc
- 23. 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%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 24. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 25. 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% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 26. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 27. 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
- 28. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 29. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth ECMO
- 30. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth The oxygenator in veno-‐venous ECMO
- 31. ECMO Study type Year pub N (ECM O) N (non ECMO) % H1N1 ECMO mortalit y Non- ECMO mortality p RCT 200 9 90 90 0 37% 50% 0.07 RCT 199 4 21 19 0 67% 58% 0.8 RCT 197 9 48 42 0 90% 92% 0.84 Cohort 200 6 32 118 0 47% 29% 0.06 Cohort 200 0 62 183 0 45% 39% NS Cohort 199 7 49 73 0 45% 11% <0.001 Case series 200 9 68 133 100% 23% 13% 0.06 Case series 201 1 69 11 100% 27.5% ?52% ***
- 32. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 33. 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%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 35. CO Monitoring – COMET-‐UK • Survey to all UK ICUs • Respondents – Majority used CO monitoring • Oesophageal doppler 57% • LiDCO 43% • PiCCO 42% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth How does doppler work? ThermodiluTon? Pulse contour analysis ?
- 36. CO Monitoring Academic Department of Critical Care Queen Alexandra Hospital Portsmouth How does doppler work? ThermodiluTon? Pulse contour analysis ?
- 37. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • 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
- 38. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth SEPSIS
- 39. The Sepsis Studies Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 40. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 41. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 42. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 43. 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% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 44. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 45. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 46. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 47. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 48. Steroids in Sepsis Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 49. The evidence…..let’s give it Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 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)
- 50. The evidence…..perhaps don’t give Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 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
- 51. Hang on…. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 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
- 52. VASST Academic Department of Critical Care Queen Alexandra Hospital Portsmouth -‐ 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
- 53. VANISH Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 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
- 54. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 55. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 56. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 57. 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) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth “lets talk about fluid responsiveness”
- 58. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 59. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 60. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 61. 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% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 62. 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
- 63. 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 -‐ Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 64. GastrointensTnal
- 65. Need a nice summary? Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Open Access! #FOAMcc
- 66. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 67. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 68. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 69. SystemaTc review: CCM 2010 In those paTents receiving enteral nutriTon, stress ulcer prophylaxis may not be required and may actually increase VAP Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 70. 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% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 71. 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%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 72. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 74. TRAUMA
- 75. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 76. PROPPR Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 77. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 78. 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’ Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 79. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 80. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • Transfusion Triggers • Blood conservaTon • Pre-‐transfusion clinical assessment • Rate of transfusion/fluid balance • InvesTgaTon adverse events • Storage duraTon
- 81. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth A Trial of Intracranial-‐Pressure Monitoring in TraumaTc Brain Injury Randall M. Chesnut et al N Engl J Med 2012; 367:2471-‐2481
- 82. Neuro Academic Department of Critical Care Queen Alexandra Hospital Portsmouth hyp://www.wessexics.com/WICS_Guidelines/ The SAH secTon definitely worth a read for the exam
- 83. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 84. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 85. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 86. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 87. TreaTng Delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 101 MV paOents RCT haloperidol vs. ziprasidone vs placebo 21/7 study period No difference in any of the groups!
- 88. 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
- 89. 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
- 90. Don’t forget the simple things…. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • Small RCT 136 paTents • Used NEECHAM score • Delirium (20%) similar but less mild confusion with ear plugs and good night sleep <50% vs. 25%
- 91. Guidelines for managing delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 92. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth CCM 2013
- 93. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 94. 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 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 95. 5 steps to keep up with the literature afer the exam Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 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
- 96. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth & Book your place at #smaccUS & ICSSOA2015
- 97. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Best of Luck! www.wessexics.com @WessexICS @WICSBoyomLine @stevemathieu75