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PINCER - Hot Topics Sept 2016

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Hot Topics presentation from Portsmouth INtensive Care Exam Revision Course

23rd Sept 2016

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PINCER - Hot Topics Sept 2016

  1. 1. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Hot Topics in ICM @stevemathieu75 Consultant in Intensive Care Medicine Queen Alexandra Hospital, Portsmouth 23rd September 2016
  2. 2. • International, multicenter RCT • 52 centres (mostly UK) • 408 patients randomised • Decompressive craniectomy vs. Medical management (barbiturates) if ICP > 25mmHg • Outcomes: death and GOS-E at 6 & 12 m • Fewer deaths in surgical group 30% v 52% (at 12m) • Estimated that for every 100 patients treated with surgery: 22 more survivors. Of these 22 – 27% VS; 36% LSD; 36% USD or better In patients with a traumatic brain injury (TBI) and refractory intracranial hypertension, does decompressive craniectomy, result in more favourable mortality and neurological outcomes at 6 months, compared with barbiturate coma and continued medical management? Trial of Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension Hutchinson. NEJM 2016
  3. 3. • RCT 47 centres, 18 countries • 387 patients • Therapeutic hypothermia (32-35C) for at least 48 hours and continued until ICP controlled + standard care vs. standard care if ICP > 20mmHg > 5mins after stage 1 treatment • Good outcome (GOS-E) – 25.7% in hypothermia group vs standard care group 36.5% In patients with TBI, does hypothermia (32-35C) and standard care compared to standard care alone reduce death and major disability at 6 months after injury? Trial of Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension Hutchinson. NEJM 2016
  4. 4. • In moderate or severe TBI does EPO improve neurological outcome? • Neuroprotective effects ? Reduce apoptosis • RCT, 29 countries; 606 patients • 40000 IU of EPO x 3 vs. placebo • Neurological disability at 6/12 or mortality – GOS-E 1-4: 44% vs 45% – 6/12 mortality 11% vs 16% – DVT 16% vs 18% In patients with moderate or severe traumatic brain injury does the administration of erythropoietin compared with placebo improve neurological outcome at 6 months after injury? Erythropoietin in traumatic brain injury: a double-blind randomised controlled trial
  5. 5. • International RCT • 1000 patients randomised if SBP > 180mmHg • Intervention: – Target systolic BP 110 to 139 mmHg throughout the 24 hours after randomisation vs. – Target systolic BP 140 to 179 mmHg throughout the 24 hours after randomisation – Nicardipine and labetalol in both groups • Primary outcome: Proportion of patients who had modified Rankin scores 4 to 6 at 3 months (significant disability or death) – No difference between groups (38.7% in intervention, 37.7% in control) • Secondary outcome: – No difference in death, haematoma volume at one week – Intensive group 5% more likely to develop AKI • NB trial halted at 1000 patients because of futility http://pulmccm.org/main/2016/n-engl-j-med-review/blood-pressure-goals-intracerebral-hemorrhage-atach-ii/ In patients with acute intracerebral haemorrhage and who are hypertensive, does rapid lowering of systolic blood pressure compared to standard therapy improve patient outcomes ? Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage
  6. 6. • 18 UK ICUs’ • 2 x 2 factorial design • 421 patients randomised • Intervention: – Study Drug 1: Vasopressin (titrated up to 0.06 U/min) or Norepinephrine (titrated up to 12 μg/min) – Study Drug 2: Hydrocortisone (50mg 6 hourly and then weaned) or Placebo – If the patient was still hypotensive after the first dose of study drug 2 then additional open-label catecholamine vasopressors could be administered • Open labelled vasopressor was permitted for up to 6 hours before enrolment to this study. Once study drug one was commenced, the open labelled vasopressor was weaned off as quickly as possible • Primary outcome: the number of days alive and free of kidney failure at 28/7 – Around 55-60% for all groups • Fewer patients required RRT in the VA group compared with the NADR group. These patients were mostly the non-survivors Does early vasopressin use reduce the risk of kidney failure in patients with septic shock compared with norepinephrine? Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock
  7. 7. • RCT 15 ICUs Australia • Is Dexmedetomidine effective in reducing the incidence of agitated delirium and days on a ventilator? • Adult ICU patients who needed to remain mechanically ventilated because their degree of agitation was considered so severe as to make lessening their sedation and extubation unsafe • Primary outcome: Statistically significant increase in median ventilator free hours at 7 days in the dexmedetomidine group 144.8 vs. 127.5 hours, P=0.01 • Patients in the placebo group received significantly more antipsychotics meds (65.6% vs 36.8%, 95% CI -51.3,-6.3%, p=0.02), more opioid, and a significantly higher dose of propofol for the 7-days after randomisation. Is Dexmedetomidine effective in reducing the incidence of agitated delirium and days on a ventilator? Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients with Agitated Delirium
  8. 8. • RCT. 31 ICUs in France • 620 patients • Initiation of RRT within 6 hours vs later following confirmation of KDIGO stage 3 • Primary outcome: mortality at 60 days – no significant difference – 48.5% in early vs. 49.7% in delayed, P=0.79 In critically ill patients with acute kidney injury does delayed compared with early initiation of renal replacement therapy (RRT) reduce mortality at 60 days? Initiation Strategies for RRT in the Intensive Care Unit
  9. 9. • RCT. Single centred • 230 patients • 5 inclusion criteria including KDIGO stage 2 • Initiation of RRT within 8 hours vs 24 hours of confirmation of KDIGO stage 2 In critically unwell patients with acute kidney injury, does early initiation of renal replacement therapy (RRT) compared to delayed initiation reduce all cause mortality at 90 days? Effect of Early vs Delayed Initiation of RRT on Mortality in Critically Ill Patients With Acute Kidney Injury
  10. 10. • French multicentre RCT • 380 patients • Acetazolamide vs placebo for up to 28d to patients with COPD and a metabolic alkalosis (primary or mixed), receiving invasive mechanical ventilation • Primary outcome: No statistical difference in the median duration of invasive ventilation between groups – 136.5 hours (IQR 68.7 – 234.7 hours) in the acetazolamide group vs. 163.0 hours (IQR 86.2 – 242.9 hours) in the placebo group; P=0.17 • Daily median serum bicarbonate change (mEq/L) – Reduction in bicarbonate in acetazolamide group: -0.3 vs. 0.3; P=<0.001 • Median number of days with a metabolic alkalosis was fewer in acetazolamide group – 2 vs 4 days; P=<0.001 Does acetazolamide reduce the duration of mechanical ventilation in critically ill patients with chronic obstructive pulmonary disease (COPD) and metabolic alkalosis? Effect of Acetazolamide vs Placebo on Duration of Invasive Mechanical Ventilation Among Patients with Chronic Obstructive Pulmonary Disease
  11. 11. • RCT 23 ICU’s in Oz/Nz. 700 patients • 1g paracetamol 6 hourly vs placebo up to 28 days • ?immunomodulatory • Median ICU-free days to day 28: no significant difference – 23 (IQR 13-25) in the paracetamol group vs 22 in the placebo group (IQR 12-25) CI 0-1; P=0.07 • all cause mortality at 28 days – no significant difference13.9% vs 13.7% • all cause mortality at 90 days – no significant difference15.9% vs 16.9% • Liver dysfunction necessitating stopping study drug – lower in paracetamol group8.1% vs 9.9% Does the regular administration of paracetamol to critically ill patients with fever and known or suspected infection, affect the number of ICU-free days? Acetaminophen for Fever in Critically Ill Patients with Suspected Infection
  12. 12. In critically ill patients, does the use of a balanced crystalloid solution compared to normal saline effect the incidence of acute kidney injury? Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomised clinical trial • RCT 4 ICU’s in Oz/Nz. 2278 patients • 0.9% NaCL vs Plasmalyte (median 2000mls each) • Primary outcome: proportion of patients with AKI based on RIFLE criteria (‘injury’ or greater and based solely on creatinine component) within 90 days of enrolment: no statistical difference - 9.6% in intervention group vs 9.2% in control group; P=0.77 • Secondary outcome: Plasma-Lyte 148 vs. 0.9% sodium chloride – no statistical difference in any of the following: - RRT requirement; mechanical ventilation; LOS; all cause mortality
  13. 13. NEW DEFINITION SEPSIS life-threatening organ dysfunction caused by a dysregulated host response to infection Septic Shock: Sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65mmHg and having a serum lactate level >2mmol/L (18mg/dL) despite adequate volume resuscitation. Sepsis 3 Organ dysfunction = acute change in total SOFA score ≥2 points due to the infection (The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction) A SOFA score ≥2 = mortality risk of approximately 10%; Septic shock = mortality > 40% Screening Patients ? Sepsis: Patients with suspected infection that are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at bedside with qSOFA. Less robust but no lab tests Thanks to REBEL EM for images http://rebelem.com/sepsis-3-0/
  14. 14. The Sepsis Studies
  15. 15. Does cognitive function in TTM cardiac arrest survivors differ between the 33 and 36 degree groups and also compared with a cohort of patients who sustained STEMI but no cardiac arrest •652 cardiac arrest survivors from TTM •Survival until 6/12 52% - invited to follow up - about half had psychometric testing - compared with a control group (STEMI & PCI but no cardiac arrest) •About 50% had cognitive impairment •33 vs. 36 vs. control group - cognitive outcome no different between temperature groups - attention & mental speed more affected in cardiac arrest patients- - memory & executive functioning similar in all groups Cognitive Function in Survivors of Out-of-Hospital Cardiac Arrest After TTM at 33ºC Versus 36ºC
  16. 16. In organ donors, following diagnosis of BSD, does TH decrease delayed graft function in kidney recipients? •2 organ procurement centres in US •RCT 394 donors •Mild hypothermia (Target 34 – 35C) vs Normothermia (Target 36.5 – 37.5C) •Delayed graft function - the recipient’s requirement for dialysis during the 1st week post-transplantation - 28.2% vs 39.2%, P=0.008 Cognitive Function in Survivors of Out-of-Hospital Cardiac Arrest After TTM at 33ºC Versus 36ºC
  17. 17. In paediatric patients with septic shock, does adrenaline compared with dopamine reduce 28 day mortality? •RCT; single centre Brazil •120 patients •Adrenaline vs dopamine after 20mls/kg bolus •Once 60mls/kg fluid given, if still shocked, clinician choice of vasoactive drug •28 day mortality - Adrenaline group vs Dopamine group 0.7% vs 20.6% Double-Blind Prospective Randomized Controlled Trial of Dopamine vs Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock
  18. 18. CALORIES • Open, multicentre, RCT • 2400 patients 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: – Vomiting 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
  19. 19. In adult patients with alcoholic hepatitis, does prednisolone and / or pentoxifylline compared to placebo reduce mortality? •RCT 65 UK hospitals •Pentoxyfylline + placebo vs. Prednisilone + placebo vs. both vs placebo x 2 •ICUs in Canada and France; 2510 patients •28d mortality no statistical difference STOPAH: Prednisolone or Pentoxifylline for Alcoholic Hepatitis
  20. 20. • In ICU patients who require a CVC, does the choice of insertion site affect the complication rates? • 10 ICUs in France (4 university hospitals and 5 general hospitals) • SC, IJ or femoral (>1000 lines in each group) • Composite measure of CRBSI and DVT • SC = lower infection; higher PTX Academic Department of Critical Care Queen Alexandra Hospital Portsmouth PERMIT
  21. 21. • Is “fresh” blood (stored for 8 days or less) better than old (stored 2-42 days)? • RCT 64 ICUs in Canada and France; 2430 patients • RBCS: 6 days vs 22 days • 90 day mortality (37% vs. 35%) • Transfusion triggers and processes for safe administration of blood are probably more important Academic Department of Critical Care Queen Alexandra Hospital Portsmouth PERMIT
  22. 22. TRISS • RCT 32 general ICUs in Scandinavia • 998 patients with septic shock & Hb <9 • Transfusion threshold <7 vs. <9 • Excluded patients with ACS • Mortality at 90 days (43% vs 45%) • Secondary outcomes • Vasoactive drugs • Ventilation • RRT • % of days alive & out of hospital • Ischaemic events Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  23. 23. TITRe2 • In adults undergoing cardiac surgery, does a restrictive transfusion strategy vs liberal one lead to fewer infections and ischaemic events within 3 months? • RCT 17 cardiac ICUs in UK • Trigger Hb 75 vs 90g/dl • Composite outcome of serious infections or ischaemic events within 3/12 – 35% vs 33% TRICC, TRISS, Villanueva Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  24. 24. PROPPR • RCT in 12 N. American Level 1 trauma centres • 680 patients • 1:1:1 vs. 1:1:2 FFP / plt / PRBCs • 24 hour and 30d mortality no different • Time of haemostasis; Any of 23 pre- defined complications; Hospital, ventilator & ICU free days • Post- hoc analysis: - Death by exasanguination in 1st 24 hrs much less in 1:1:1 group Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  25. 25. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Guidelines
  26. 26. Standards - quality • Staffing – Consultant presence • 24/7 & within 30 minutes – Consultant: patient 1:8 – 1:15; ICU resident/patient 1:8 – Designated CD – Ward rounds x2 daily – Training / FICM / Board Tutors – Nursing 1:1 (level 3); 1:2 (level 2) – MDT e.g. physio, pharmacy, dieticians • Operational – Large ICUs divided into pods of 8-15 patients – Admit within 4 hrs of decision to admit – Avoid non-clinical transfers – Transfer to ward – clear and formalised – Out of hours transfers – Readmission within 48 hours bad – Assessment of rehab for each patient • Equipment – Training • Data Collection – ICNARC – Risk register Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Quality Indicators SMR Scoring Systems
  27. 27. •Definitions: CPIS, CDC, HELICS •Pathogens: - Early: strep pneumonia; H.influenzae; MSSA; Klebsiella, E.Coli - Late: MRSA, acinetobacter, pseudomona •Elevation of head of bed (30-45 degrees) •Daily sedation interruption and assessment of readiness to extubate •Use of subglottic secretion drainage •Avoidance of scheduled ventilator circuit changes •? Stress ulcer prophylaxis •? Avoid oral chlorhexidine • Reduces nosocomial pneumonia in cardiac surgery • Meta-analyses showing benefit heavily influenced by cardiac patients • No benefit for VAP in general ICU’s •ICUs in Canada and France; 2510 patients •28d mortality no statistical difference https://ccforum.biomedcentral.com/articles/10.1186/cc13775 ICS Recommended bundle of interventions for the prevention of ventilator associated pneumonia
  28. 28. 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 unanticipated ICU admission Prolongation ICU stay Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  29. 29. 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
  30. 30. Recommendations Capnography Airway equipment Back up planning Staffing Patient transfers Education/training Tracheostomy tube design Team working Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  31. 31. Tracheostomy standards • Indications for tracheostomy • Cautions and contraindications • Consent • Equipment • Ultrasound • Anaesthesia • Staffing • Types of tracheostomy tubes • Inner cannulae • Complication – Early – Late – Airway emergencies T R A C H E O S T O M Y C A R E I N T E N S I V E C A R E S O C I E T Y S T A N D A R D S © 2 0 1 4
  32. 32. Antibiotic Stewardship https://www.ficm.ac.uk/sites/default/files/FICM-Start_Smart_Then_Focus_FINAL.pdf
  33. 33. Community Acquired Pneumonia https://www.nice.org.uk/guidance/cg191/chapter/1-Recommendations#community-acquired-pneumonia-2
  34. 34. Brain Trauma Foundation Guidelines 22nd Sept 2016 https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/:guideline
  35. 35. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth http://www.britishinfection.org/files/5614/5674/2938/McGill_meningitis_guidelines_Final_published_proof.pdf
  36. 36. Guidelines for managing delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  37. 37. Designing a new Intensive Care Unit
  38. 38. Fire on the ICU 1. Protect patients and staff 2. Manage fire hazard 3. Identify cause and prevention Management of Fire Hazard – RACER RESCUE ALERT CONTAIN EXTINGUISH RELOCATE
  39. 39. Care of the dying patients (2015) https://www.nice.org.uk/guidance/ng31 Rehabilitation after Critical Illness (2015) https://www.nice.org.uk/guidance/cg83 AKI: Prevention, Detection and Management (2013) https://www.nice.org.uk/guidance/cg169 AF Management (2014) https://www.nice.org.uk/guidance/cg180
  40. 40. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Useful resources
  41. 41. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Useful resources
  42. 42. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Useful resources
  43. 43. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Useful resources
  44. 44. Neuro Academic Department of Critical Care Queen Alexandra Hospital Portsmouth http://www.neuroicu.org.uk/ The SAH section definitely worth a read for the exam The SAH section definitely worth a read for the exam
  45. 45. Critical Care Reviews
  46. 46. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 2014 & earlier
  47. 47. ALBIOS • RCT, 100 ICUs in Italy • 1795 patients with severe sepsis • 300mls 20% HAS daily + CSL vs. CSL • Target serum albumin 30g/dl • 287 mortality: no different – HAS + CSL: 31.8% – CSL: 32% • Secondary outcomes: 90 d mortality – No difference Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  48. 48. ARISE • Randomised, controlled, multicentre, • 51 hospitals 1,600 patients with septic 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
  49. 49. ProCESS • RCT 31 ICUs in US • 03/2008 – 05/2013 • 1351 patients with septic 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
  50. 50. CALORIES • Open, multicentre, RCT • 2400 patients 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: – Vomiting 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
  51. 51. PEITHO • RCT; 13 countries; 1006 patients • Tenecteplase vs placebo • Death or haemodynamic decompensation within 7 days – Significantly lower in thrombolysis group – 2.6% vs. 5.6% in placebo group (NNT 34) • Mortality at 7 days and 30 days – 7 days: 1.2% vs. 1.8%; 30 days: 2.4% vs. 3.2% • Major extracranial bleeding - higher in thrombolysis group – 6.3% vs. 1.2% (NNH 19) • Haemorrhagic stroke – higher in thrombolysis group – 2% vs 0.2% (NNH 55) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  52. 52. HARP 2 • 540 patients ARDS; 40 UK ICUs • ARDSnet +/- statin for 28 days (80mg od simvastatin) • Primary outcome – No difference in ventilator free days at 28d • Secondary outcome – No difference in SOFA, oxygenation – Elevated CK or ALT/AST > in statin group Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  53. 53. CATIS • 4,071 patients • Within 48 hrs ischaemic stroke • nonthrombolysed and ↑BP • Hypertension therapy vs no BP Rx • BP control effective • No difference – death and major disability • 14 days / hospital discharge • 3 months Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  54. 54. CRISTAL Study • Stratified open label RCT • Recruitment over 9 years • Any colloid vs any CSL • 2857 patients with hypovolaemic shock • 28 day mortality • Colloids favoured: – 90 day mortality (30% vs 34%) – More days alive without MV – More days alive without vasopressors – Less RRT - Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  55. 55. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth http://www.britishinfection.org/files/5614/5674/2938/McGill_meningitis_guidelines_Final_published_proof.pdf
  56. 56. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Themes
  57. 57. 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 unanticipated ICU admission Prolongation ICU stay Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  58. 58. 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
  59. 59. Recommendations Capnography Airway equipment Back up planning Staffing Patient transfers Education/training Tracheostomy tube design Team working Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  60. 60. TracMan - 2013 •Early tracheostomy (by d 4) or late (>10/7) – 455 patients – Mortality the same 31% – LOS the same 13 d – Complications 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
  61. 61. ARDS
  62. 62. ARDS - Incidence • 1 yr prospective observational study; 255 patients • Incidence 7.2/100,000/year (? US 75/100,000) • Despite use of lung protective ventilation overall ICU mortality >40% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  63. 63. ARDS - lots of trials
  64. 64. OSCAR • 795 patients with moderate - severe ARDS (<26.7kPa / 200mmHg) • CMV vs. HFOV (MV <7 days) • No difference in – 30/7 mortality (41%) – Duration antimicrobial agents (2/3 chest sepsis) – Vasoactive support duration – ICU LOS – Hospital LOS Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  65. 65. OSCILLATE • 548 patients 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 sedation – More NMBA’s – More vasopressors Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  66. 66. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  67. 67. PROSEVA • 466 patients with severe ARDS • Prone position vs supine position • Prone position was associated with – Improved mortality • 28 day: 16% vs 33% • 90 day: 24% vs 41% – Less cardiac arrests – No difference in complications Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  68. 68. PROSEVA Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  69. 69. Statins in ARDS • Multicentre, RCT • Rosuvastatin vs. placebo in ARDS • Statin may modulate inflammatory response • 745 patients (trial stopped early because of futility) • Primary outcome: • 60d mortality: 28.5% vs. 24.9% (statin vs. placebo) • Ventilator free days: 15.1 vs. 15.1 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  70. 70. Statin & VAP • 300 patients with suspected VAP (CPIS ≥ 5) • Simvastatin 60mg vs placebo • No difference in – 28d survival – ICU or hospital mortality – Duration MV – Delta SOFA • Increased mortality in statin naieve Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  71. 71. BALTI - 2012 • 162 patients; 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
  72. 72. Steroids in ARDS • 9 studies (4 RCT’s & 5 cohort) • 648 patients • Trend to reduced mortality but only ss when result pooled • Trials vary ++ 1. Dose 2. Initiation of treatment 3. Course length 4. Not all studies report adverse events Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  73. 73. Functional disability 5 years after ARDS 109 survivors from ’98 - ’01 Interview, PFT’s, 6 min walk test, resting & 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
  74. 74. Nitric oxide – just say No • Potent pulmonary vasodilator which when inhaled = selective vasodilation in well ventilated lung units • Improved V/Q mismatch and PVR & PAP • Also anti-inflammatory effects • Systematic review of 12 trials with 1200 patients = improved oxygenation d1, no improvement in mortality • AKI and methaemaglobinaemia intracranial bleeding in children Afshari Cochrane review 2007 - adults Barrington Cochrane review 2010 – children Afshari – systematic review 2011 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  75. 75. Magnesium in asthma • 1200 patients 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
  76. 76. • In ICU patients undergoing intubation does apnoeic oxygenation during laryngoscopy increase the lowest arterial oxygen saturation experienced by patients • Single centre • HFNC + other NRBM/BiPAP/BVM/standard nasal vs. NRBM/BiPAP/standard nasal cannulae • Median lowest SpO2 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth PERMIT
  77. 77. • 12 French ICU’s; 310 patients • ‘ALI’ • NRB vs HFNC vs NIV • Proportion of patients who required endotracheal intubation within 28 days after randomisation: • High-Flow oxygen: 40 patients (38%) • Non-invasive ventilation: 55 patients (50%) • Standard oxygen: 44 patients (47%) • p = 0.18 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth PERMIT
  78. 78. NCEPOD 2014: Tracheostomy • Documentation & consent – Indications, type, inner tube, reasons for failed extubation/why no trial of extubation • Different types of tubes • Rapidly available difficult airway trolley • Training programmes in blocked/displaced tubes • Capnography • Discharge of patients with tracheostomy • MDT – physio & SALT Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  79. 79. Tracheostomy standards • Indications for tracheostomy • Cautions and contraindications • Consent • Equipment • Ultrasound • Anaesthesia • Staffing • Types of tracheostomy tubes • Inner cannulae • Complication – Early – Late – Airway emergencies T R A C H E O S T O M Y C A R E I N T E N S I V E C A R E S O C I E T Y S T A N D A R D S © 2 0 1 4
  80. 80. MCA & DoLS DoLS • 3 cases in 2014 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  81. 81. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  82. 82. 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
  83. 83. 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 patients • The question: 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
  84. 84. Delirium HOPE ICU • 142 patients with delirium • CAM-ICU assessment • Double blinded • Haloperidol vs. placebo • No change in duration of delirium in critically ill patients • Haloperidol should be reserved for short term management on acute agitation Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (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
  85. 85. Treating Delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth 101 MV patients RCT haloperidol vs. ziprasidone vs placebo 21/7 study period No difference in any of the groups!
  86. 86. The beginning; Kress NEJM 2000 Reduction in LOS Girard Lancet 2008 Decreased ICU stay, time on ventilator and mortality Strom Lancet 2010 Reduction in LOS and ventilator days No sedation group - boluses of morphine, well established in institution, more agitated delerium in no sedation group Jacob JAMA 2012 PRODEX/MIDEX No better than midaz or propofol at maintaining light to mod sedation and more adverse effects. Increased patient interactions. Less vent days than midazolam Ryker JAMA 2009 Reduction in ventilator days and delirium Mehta 2013 For MV patients managed with protocolised sedation, the additon of daily sedation interruption did not reduce duration MV or ICU LOS
  87. 87. Don’t forget the simple things…. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • Small RCT 136 patients • Used NEECHAM score • Delirium (20%) similar but less mild confusion with ear plugs and good night sleep <50% vs. 25%
  88. 88. Guidelines for managing delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  89. 89. Neuro-ICU ICP Monitoring • Multicentre RCT of 324 patients 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 Traumatic Brain Injury Randall M. Chesnut et al N Engl J Med 2012; 367:2471-2481
  90. 90. Neuro Academic Department of Critical Care Queen Alexandra Hospital Portsmouth http://www.wessexics.com/WICS_Guidelines/ The SAH section definitely worth a read for the exam The SAH section definitely worth a read for the exam
  91. 91. 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 antibiotics would you use? How can you reduce incidence
  92. 92. 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 function at 180 days 33°C (54%) with 36°C (52%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  93. 93. Pre-hospital hypothermia • Prehospital cooling vs. standard care • 2L of cold normal saline once ROSC • 1,359 OOHCA patients • Cooling effective (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
  94. 94. 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? Thermodilution?Pulse contour analysis ? How does doppler work? Thermodilution?Pulse contour analysis ?
  95. 95. OPTIMISE • RCT, multicentre, 17 UK ICUs • 734 patients • > 50y undergoing GI surgery with one or more ‘high risk’ risk factors • Algorithm-directed care dictating colloid and dopexamine administration using vs. clinician directed care without use of CO monitoring • Primary outcome: composite of 30d mortality and mod/major complications – Intervention: 36.6% – Control arm: 43.4% • No SS difference in secondary outcomes – POMS, infectious complications, critical care free days at 30d, mortality at 30d and 180d, hospital LOS Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  96. 96. IVOIRE Study • Randomised, open study • 18 ICU’s in France, Belgium and Netherlands 2005-2010 • 140 pts with septic 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
  97. 97. IABP – SHOCK II • 600 patients with cardiogenic shock secondary to AMI • IABP vs no IABP • All received early revascularisation 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 reinfarction rate Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  98. 98. VSE in cardiac arrest • 268 patients 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 dysfunction • andAcademic Department of Critical Care Queen Alexandra Hospital Portsmouth
  99. 99. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  100. 100. CHEER • Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion • 26 patients (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 patients – Survival to hospital discharge 14/26 (54%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  101. 101. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth The oxygenator in veno-venous ECMO
  102. 102. 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% ***
  103. 103. ECMO for H1N1 • 2009-2010 • 80 patients referred for ECMO • 69 received ECMO • 22 of these died (27.5%) • Matching cohort = 52% • For patients with H1N1 related ARDS, mortality reduced with ECMO Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  104. 104. Passive Leg Raise
  105. 105. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • Meta-analysis • 16 trials inc PEITHO, MAPPETT, MOPETT, TOPCOT • Thrombolysis + anticoagulation vs. anticoagulation alone • All cause mortality less in thrombolysis group but major bleeding & ICH higher
  106. 106. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth SEPSIS
  107. 107. Ferrer: Empiric antibiotics in sepsis • Retrospective observational cohort study • 165 ICUs – Europe, US & S America • Jan 2005- Feb 2010 • 18,000 patients with septic shock • Delay in antibiotics administration over first 6 hours after identification of SS or septic shock -> increased mortality • < 1 hr 24.6%; 1-2h 25.9% > 6h 33% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  108. 108. SEPSISPAM • RCT, multicentre, 29 French ICUs • March 2010 – Dec 2011 • Septic 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 creatinine and need for RRT was lower in higher MAP group Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  109. 109. PROWESS SHOCK • Randomised, controlled, multicentre, parallel group study • 1,697 patients with septic 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
  110. 110. B blockers in septic shock • Open label, single unit • Septic shock + HR ≥ 95 + NADR • 77 patients – esmolol infusion (HR 80- 94) vs 77 patients 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
  111. 111. Esmolol in refractory VF • Single centre, non randomised • 25 patients with refractory (>3 defib attempts) 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
  112. 112. Steroids in Sepsis Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  113. 113. ADRENAL Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  114. 114. 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 time for shock resolution - More secondary infections - Higher doses and for shorter periods 19 ICU’s 300 patients - 50mg hydrocortisone + fludrocorisone vs. placebo by 8hrs of onset of septic shock. - ‘Non responders’ (adrenal suppression) better ICU (53% vs. 63%) and hospital mortality (61% vs. 72%). - Increase secondary bacterial infections - NNT = 7 (Annane JAMA 2002)
  115. 115. The evidence…..perhaps don’t give Academic Department of Critical Care Queen Alexandra Hospital Portsmouth CORTICUS - 52 ICU’s, 499 patients - 50mg hydrocortisone QDS vs. placebo 6/7 - 28/7 mortality no different between groups and subset of non- responders Quicker shock resolution, catecholamine sparing, more secondary infections Sprung et al. NEJM 2008: 358; 111-24 - Etomidate used in 1/5th of patients - Only 35% power to detect a 20% mortality reduction - High variability between laboratories in cortisol assays
  116. 116. VASST Academic Department of Critical Care Queen Alexandra Hospital Portsmouth - RCT 778 pts with septic 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
  117. 117. ABLE Multicentre UK RBC transfusion (7d vs. 15-25d) Transfusion triggers – TRICC, TRISS & Villaneuva, TITRe2 PROPPR: Plasma, Platelets & PRBC’s 1:1:1 vs. 1:1:2 Guidelines on the management of anemia and RBC transfusion in adult critically ill patients (BCSH Guidelines 2012) Serious Hazards of Transfusion (SHOT) – JICS July 2013
  118. 118. TRISS • RCT 32 general ICUs in Scandinavia • 998 patients with septic shock & Hb <9 • Transfusion threshold <7 vs. <9 • Excluded patients with ACS • Mortality at 90 days (43% vs 45%) • Secondary outcomes • Vasoactive drugs • Ventilation • RRT • % of days alive & out of hospital • Ischaemic events Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  119. 119. Acute UGI Bleed • Randomised, parallel group study • 921 pts with severe upper GI bleeding • Compared restrictive (Hb <7g/dL) vs liberal transfusion strategy (Hb<9g/dL) • Restrictive 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
  120. 120. TXA CRASH - 2 Lancet 2010 • tranexamic acid in reducing transfusion requirements and death from significant haemorrhage following injury • 20,000 patients • Risk of haemorrhage reduced by 0.8% • No reduction 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 effective if within first 3 hours. Beyond this time mortality increases Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  121. 121. TXA CRASH – 2 Does TXA reduce the risk of intracranial bleeding in patients with TBI? BMJ 2011 • 250 of the 20,000 patients eligible. • Brain haemorrhage growth 5mm vs. 8mm (TXA vs. placebo) • Not SS • No mention 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
  122. 122. Trauma Haemorrhage 1. Coagulation monitoring and measures to support coagulation should be implemented early 2. Damage control surgery 3. Physiological targets, suggested use & dosing of fluids, blood products and TXA 4. Patients on antiplatelet agents and/or oral anticoagulants require special attention 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
  123. 123. Fluids • Don’t give too much • Don’t give too little • Make sure you give the right amount • Starches bad…very bad Association of HES administration with mortality and AKI in critically ill patients requiring volume resuscitation. 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 resuscitation fluid for patients with sepsis. 17 studies, 1977 patients. Crit Care Med 2011 Albios Study – Gattinoni (video ion ESICM website) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth “lets talk about fluid responsiveness” NO!
  124. 124. ESICM statement on colloids 1. Recommend not to use HES with mw ≥ 200kDa in patients with severe sepsis or risk of AKI 2. Suggest avoid 6% HES or gelatin in these groups 3. Recommend not to use colloids in patients with head injury and not to administer gelatins and HES in orhan donors 4. Suggest avoid hyperoncotic solutions for fluid resuscitation Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  125. 125. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  126. 126. 6S Study • 804 ICU pts with severe sepsis • Compared fluid resuscitation – 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
  127. 127. CHEST Study • 7000 ICU pts • Fluid resuscitation 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 / Hepatic failure -Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  128. 128. Gastrointenstinal
  129. 129. • In patients with severe pancreatitis, does early enteral feeding compared with on-demand feeding reduce death or major infection? • RCT; Netherlands; 208 patients • Early NJ within 24 hours vs IV fluids + ‘on demand’ • Composite outcome of death or major infection within 6 months Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  130. 130. • In critically ill adults, does restriction of non-protein calories (permissive underfeeding) compared to standard feeding reduce mortality at 90 days? • RCT; Saudi Arabia and Canada; 894 patients • Permissive enteral underfeeding (40-60%) vs standard (70-100%) for up to 14 days • ? Moderate survival benefit from permissive underfeeding with moderate caloric intake (around 50% of target calories) and maintenance of full protein requirement (1.2-1.5g per kg per day) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth PERMIT
  131. 131. Need a nice summary? Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  132. 132. The SuDDICU study SDD 12 meta-analyses of 28 RCT’s. 10 show reduced pneumonia rate; 6 show morality benefit • Why have clinicians avoided implementing it in UK? • What are the barriers? • What further evidence is required before full scale clinical implementation Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  133. 133. VITdAL-ICU • RCT, Single Centre with 5 ICUs in Austria, 475 patients • 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
  134. 134. Systematic review: CCM 2010 In those patients receiving enteral nutrition, stress ulcer prophylaxis may not be required and may actually increase VAP Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
  135. 135. 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
  136. 136. Hepatology • ALD Alcohol related illness costs NHS £1.7 billion/year Systematic review of 21 articles 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 (ventilation, vasoactive drugs, RRT) Mackle - - if MV and vasoactive drugs hospital mortality 86% - If MV, vasoactive 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
  137. 137. Intraabdominal pressures http://www.wsacs.orghttp://www.wsacs.org//
  138. 138. 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 admitted with or developed IFD • Conclusion: Incidence of IFD in non- neutropenic, critically ill patients is low Academic Department of Critical Care Queen Alexandra Hospital Portsmouth

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