1. Post Resuscitation Care Dr Ian Seppelt Senior Specialist in Intensive Care Medicine, Nepean Hospital Senior Research Fellow, George Institute for Global Health, University of Sydney
2. (an introduction to basic intensive care medicine)• 95% of intensive care medicine is “getting the basics right”• The other 5% is picking up the ….
3. The other 5% is picking up the ….
4. Post Resuscitation Care1. General care – Fluid Management – Pain, sedation, delirium – Nutrition – Blood sugar control2. Post cardiac arrest – Therapeutic hypothermia – Prognosis after cardiac arrest
5. Where are we heading with intensive care research?There are no magic bullets • It is implausible that any treatment will reduce mortality by 14% • The attributable mortality of sepsis is about 10% [Bellomo, ANZICS APD, 2010] • We can realistically expect an effect size of 1-2%
6. Where are we heading with intensive care research?• What costs < $2,500/patient in ICU – Better fluid therapy or fluid balance management, – Better transfusion practices, – Better nutrition, – Better sedation – Better oxygen therapy – Better fever management, – Better setting of the ventilator knobs etc. etc. With thanks to Prof Rinaldo Bellomo
7. Getting the basics right Not toomuch, not toolittle, but just right
8. Fluid Management1. It’s not what you use but how you use it – No evidence of benefit for any one fluid over another2. Treat patient not numbers – Warm, well perfused, conscious, passing urine3. Too much fluid as harmful as not enough
9. Single centre unblindedstudy by an enthusiast …With an implausibleoutcome ……And a huge effect onemergency medicine andintensive care practice
10. ARISE Observational Cohort study• 32 sites, 324 patients, same inclusion criteria as Rivers• Mortality – ICU 18.9% (n = 58) – Hospital 20.1% (n = 62) – 28-day 22.2% (n = 72) – EGDT Study 46.5% standard arm, 30.5% EGDT arm
11. Inv Vent 18.8% ARISE interventions Arterial line 44.4% T0 toT6 hr CVC 37.0% ScvO2 line 0% Fluids 1550 (0 - 9030) ml 412 (0 – 3500) ml NA or Ad 29.9% Blood 7.7% Hct T0hr 37 (19 - 66) Hct T6hr 33 (19 – 48) Dobutamine 2.5% Median,range
12. Arterial line 44.4%Inv vent 18.8% HOW DO WE Std 53.8% Std 100%, EGDT 100% CVC 37.0% COMPARE TO EGDT 53.0% Std 100%, EGDT 100% the EGDT ScvO2 line 0% study? Std 0% EGDT 100% Total fluids 2431 (1951) ml Std 3499 (2438) ml EGDT 4981 (2984) ml Na or Ad 29.9% Std 30.3%, EGDT 27.4% Blood 7.7% Std 18.5% EGDT 64.1% Dobutamine 2.5% Std 0.8%, EGDT 13.7% Mean(SD)
13. Three large international trials now underway• ARISE (Australia and New Zealand)• PROMISE (United Kingdom)• PROCESS (USA)
14. Message no 1• A single centre trial by an enthusiast should not change practice …..• …… no matter how good the results are ……• until it has been validated in a multicentre environment• How do the results apply to YOU in YOUR hospital?
15. Fluid Management - Summary• Resuscitation fluid as necessary• After resuscitation, titrate fluid as necessary to CLINICAL end points• Too much fluid can harm – Tissue edema, organ failures – Pulmonary edema, ventilation failure• Beware the ‘accidental’ fluids
16. Pain, sedation, delirium• Three separate concepts which should be managed separately [2012 SCCM guidelines]• Many ICU patients just need pain relief – Usually an opioid, by bolus or infusion• If agitated, look for the cause – Uncomfortable or itchy – Full bladder?
17. Sedative drugs• Growing evidence that benzodiazepines cause long term problems – Neuropsychological problems – Post traumatic stress disorder• Increased volume of distribution and impaired clearance in critical illness – Midazolam is not a ‘rapid offset’ drug after an infusion
18. Sedative drugs• Sedative doses should be minimized to achieve a goal of light sedation – Calm but responsive to voice – Regular assessment of sedation depth – Consider daily interruption of sedation• Delirium – Non drug approaches? – Specific drug therapy for delirium
19. • Observational cohort study in Australian, New Zealand, Malaysia• Planning large RCT comparing an ‘anti delirium’ sedation protocol with usual practice
20. Extubation Time Mortality
21. Expected Ventilated > 24 hours, Sedation / Opioids Randomise Conventional arm Intervention Titrate to maintain arm RASS -2 to +1 Dependent on baseline care from RASS Q 4 hrs observational study for drugs and trials Dexmedetomidine CAM-ICU daily / twice Propofol Morphine or fentanylBreakthrough agitation Breakthrough agitationBreakthrough delirium Breakthrough delirium Wean ventilation as clinically tolerated and proceed 26 to Extubation once clinically feasible
22. Sedation - Summary• Think about Pain, Agitation, Delirium as three different concepts, all treated differently• Patient safety comes first• Calm and cooperative patient ideal• Excessive sedation associated with longer time on ventilator, longer time in ICU, post- traumatic stress disorder, and possibly increased mortality
23. Nutrition• Any patient expected to be in the ICU “the day after tomorrow” needs nutrition – Commence feeds within 24 hr in this group• Enteral is best – cheapest, most physiological• Parenteral nutrition reserved for those who cannot tolerate enteral – expensive, risk of sepsis
24. Nutrition• Need unit guidelines – Specific to your own environment and casemix – Even with guidelines, only expect 70 – 80% compliance• Don’t forget nutritional deficiencies – Thiamine
25. Blood sugar control• Hyperglycemia is common in critical illness, and associated with worse outcomes• ‘Intensive insulin control’• Large influence from single centre SICU study in Belgium (van den Berghe, NEJM 2001)• Results not duplicated in MICU study
26. Blood sugar control - summary• Single centre results could not be duplicated in large multicentre study• ‘Intensive insulin therapy’ caused increased mortality• Keep BSL in ‘high normal’ range – 6.0 – 10.0 mmol/l or – 110 – 180 mg/dl
27. Post Cardiac Arrest Management Return of spontaneous circulation – what next?
28. Post cardiac arrest• Emergency angiography and stenting? – Depends on local resources – Otherwise consider thrombolysis according to usual criteria• Cardiogenic shock – No clear benefit of any one inotrope or vasopressor – Titrate to physiological goals – Physical therapies (positive end expiratory pressure, IABP)
29. Therapeutic hypothermia• We know that HYPERthermia is bad in brain injury• Two trials suggest neurological benefit with either 12 or 24 hours moderate hypothermia – 32 to 34oC – Ice packs, cold fluids, cooling jackets• ILCOR recommendation• Adverse effects of hypothermia – Coagulation, electrolytes, cardiac function
30. TTM trialComparison of hypothermia with NORMOthermia after cardiac arrest?
31. Summary - hypothermia• Fever is bad in brain injury• Likely benefit of hypothermia in subgroups studied – Don’t forget exclusions – VF/VT cardiac arrest only – Not cardiogenic shock – Problems with drug metabolism – suppresion on hepatic metabolism
32. Prognosis after cardiac arrest• Used to be relatively simple – Levy criteria (JAM 1985) – No chance of regaining independence: • No pupillary light reflex • 24 hr motor response worse than flexor and no coordinated eye movements • 3 day motor response no better than flexor • 1 week not obeying commands ….
33. Wijdicks et al, Neurology 2006;67:203–210
34. Wijdicks et al, Neurology 2006;67:203–210
35. Prognosis in Hypothermia Era• None of the ‘old’ tests validated• Confounded by need for sedation to tolerate hypothermia – Too much sedation, slow metabolism, saturation of fat stores• Evidence that therapy is being withdrawn too son in patients with a good prognosis• But how long to wait?
36. PROPAC II• Multicentre prospective cohort study in Netherlands to investigate the reliability of prognosis after cardiac arrest treated woth hypothermia• Diagnostic methods – neurological examination, – neuron specific enolase (NSE) – median nerve somatosensory evoked potentials (SEP)• Outcome – 53% poor outcome; patients die in first week• Prediction poor outcome – Absent brain stem reflexes FPR 1 – NSE > 33μg FPR 7-10 – SEP normothermia FPR 0
37. Conclusions – Post Resuscitation Intensive Care
38. Conclusions - 1• ‘Not too much, not to little, but just right’• Be cautious applying magic therapies from single centre studies elsewhere in the world• Know your own environment, epidemiology and resources
39. Conclusions - 2• After resuscitation over, give just enough fluid to achieve clinical endpoints – Too much fluid as bad as not enough – Choice of fluid much less important• Sedate intelligently – Treat pain, agitation and delirium separately – Oversedation harmful
40. Conclusions - 3• Early nutrition recommended – Use enteral route if possible – Don’t forget thiamine and treat other nutritional deficiencies• Keep blood sugar ‘high normal’
41. Conclusions - 4• Post resuscitation from cardiac arrest – Treat the heart as indicated (PTCA or thrombolysis) – Hypothermia for subgroup of patients shown to benefit – Adverse effects of hypothermia – Be very careful with drugs and hypothermia
42. Conclusions - 5• Prognosis after cardiac arrest is really hard in the hypothermia era• Make no decisions until – Normothermia – You are confident of drug clearance• Compassionate approach to patient and family in social context