This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.

1. WELCOME
In Brussels
EDUCATION
IS YOUR MOST POWERFUL
WEAPON
TO CREATE THE CHANGE
YOU NEED

2. WELCOME
In Brussels

3. WiFi
•Network: 40thIntensiveCare
•Password: 40thICU@VUBJette

4. https://youtu.be/VC9dOwpGeK0

5. Code ifad19

6. #UZB40ICU
@FOAMecmo - @avkwong - @Fluid_Academy

7. Special thanks to our sponsors…

8. BRONZE

9. 09.05.2019 30th SMART 9IAH:Where are we now?(@Manu_Malbrain)
EDUCATION ISYOUR MOST POWERFUL
TO CREATE THE CHANGE YOU NEED
OCT
11
OCT
12
OCT
12
OCT
26
TO CREATE THE CHANGE YOU DESERVE

10. 09.05.2019 30th SMART 10IAH:Where are we now?(@Manu_Malbrain)3rd BEACH COURSE (OCT 11)

11. 09.05.2019 30th SMART 11IAH:Where are we now?(@Manu_Malbrain)

12. 09.05.2019 30th SMART 12IAH:Where are we now?(@Manu_Malbrain)

13. 09.05.2019 30th SMART 13IAH:Where are we now?(@Manu_Malbrain)3rd BEACH COURSE (OCT 11)

14. 09.05.2019 30th SMART 14IAH:Where are we now?(@Manu_Malbrain)
A stand-still is a no go

15. In Brussels
EDUCATION
IS YOUR MOST POWERFUL
WEAPON
TO CREATE THE CHANGE
YOU NEED

16. 09.05.2019 30th SMART 16IAH:Where are we now?(@Manu_Malbrain)
Manu Malbrain, MD, PhD
• Internist – Intensivist
• Professor Faculty of Medicine, Brussels Free University
• ICU Director, University Hospital Brussels (UZB)
• Past President, treasurerWSACS (wsacs.org)
• Co-Founder International Fluid Academy (fluidacademy.org)
• Educational Grant: 2003 ESICM Chris Stoutenbeek Award
• Member Medical Advisory Board
• Getinge
• Spiegelberg, Holtech Medical, Serenno Medical
• Consults for Cytosorbents, Baxter, Maltron, ConvaTec
• European Patent Holder: GEF/GEDVI - CiMON (PMS)
• Research Project: Draeger, Edwards, Baxter
• Fees - Honoraria: GSK, MSD, Fresenius-Kabi

17. 09.05.2019 30th SMART 17IAH:Where are we now?(@Manu_Malbrain)
Manu Malbrain, MD, PhD
• Internist – Intensivist
• Professor Faculty of Medicine, Brussels Free University
• ICU Director, University Hospital Brussels (UZB)
• Past President, treasurerWSACS (wsacs.org)
• Co-Founder International Fluid Academy (fluidacademy.org)
• Educational Grant: 2003 ESICM Chris Stoutenbeek Award
• Member Medical Advisory Board
• Getinge
• Spiegelberg, Holtech Medical, Serenno Medical
• Consults for Cytosorbents, Baxter, Maltron, ConvaTec
• European Patent Holder: GEF/GEDVI - CiMON (PMS)
• Research Project: Draeger, Edwards, Baxter
• Fees - Honoraria: GSK, MSD, Fresenius-KabiMy biggest bias = WSACS
AKA: The Abdominal Compartment Society

18. 18

19. 19
Fox Creek Wines

20. 20

21. 21

23. 23

24. Shearman CP et al. Br J Surg 1988; 75: 1273
nl 10’ 30’

27. Monroe
1765
Williams Keen
1890

28. Robinson 1948

29. Friedman and Devries 1980

30. Lundberg

32. Maintaining ICP at 20 mm
Hg or less NOT superior to
care based on imaging and
clinical examination
Chesnut et al. NEJM 2010, N=324

33. Rescue-ICP (NEJM 2016, n=408)

34. Rescue-ICP (NEJM 2016, n=408)
?

35. Visualizing the pressure and time burden of intracranial
hypertension in adult and paediatric traumatic brain injury
June 2015, Volume 41, Issue 6, pp 1067–1076

37. TTM – trial NEJM 2013 (n=939)
36
33

38. NO
Difference

39. TTM2 – trial ongoing (n=1900)
<37.7 vs 33

40. TTM2 – trial ongoing (n=1900)
<37.7 vs 33
?

42. 43

43. 48
Thegreatdiscoveries…
Stephen Hales
(1677-1761)
?
William Harvey
(1578-1657)

44. 49
MAP: 130 90 100
CurrProtocMouseBiol.2011;1:105–122
JZooWildlifeMed1992;23:205-210
HR: 90 500

45. 52
MAP
CVP
PP
MSFP
CO

46. Target blood pressure
2014

47. Target blood pressure, SEPSISPAM (NEJM 2014, n=776)
NO
Difference

48. Flow in rigid tube “Windkessel” effect
https://www.youtube.com/watch?v=Bx9Nu2PkPsE&t=52s
1733

49. 56
Preload
Heart
Venous capacitance

50. 59
Frank-Starling curve
Cardiac output
CVP
Cardiacoutput
CVP
EHStarling
(1866-1927)
SWPatterson
(1882-1960)
J Physiol. 1914 Sep 8; 48(5): 357–379
1914

51. 60
Frank-Starling curve
Cardiacoutput
CVP

52. High preload
Stroke volume
Intermediate
preload
Low preload

53. 1970

55. LANCET 2005

56. NO Difference
LANCET 2005

59. Glyco =
sweet
Calix =
husk, shell

60. Vascular lumen
Glycocalix
Endothelial cells
Subendothelial
surface layer

61. 71
PAC
APC
GDT
CCS
ScvO2
Lactate
VASO?
VIT-C?

63. 73

64. 1864Slides by Courtesy of Konstantinos Raymondos

65. 1928
1928

66. 1933
1993

67. 1937
1937

68. 1950
1950

69. 1952
1952

70. 1956
1956

71. 1950s

72. 1960s

73. 1970s

74. 1980s

75. 1990s

77. 110
CCS
HFOV
NMB
OLA
ECCOR
PRONE
FACCT
ARDSnet

79. 112

80. Malbrain ML et al: Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322
Bladder pressure measurements were performed by Mosso and Pellacani (1881)
from Italy
1881

81. Malbrain ML et al: Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322

82. Malbrain ML et al: Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-3221890
Heinricius G.
(Bern, 1890)
“Ueber den
einfluss der
bauchfulling auf
circulation und
respiration”
Zeitschrift f Biol,
1890; 26:113-202

83. Malbrain ML et al: Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322
Guy de Chauliac
(1298-1370)
describes first
abdominal
decompression
“avant la lettre”
1331

84. Malbrain ML et al: Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322
Over the years
different devices,
trocars and
techniques were
reported by
Johann
Schultneiss and
Paul Barbette to
decompress the
abdomen

85. Malbrain ML et al: Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33:315-322
Not only tubes but
also special apparatus
were invented to hold
the evacuating trocar
in place during the
drainage procedure.
NicolaasTulp (1593-
1674) warned against
too rapid drainage for
fear of sudden
death…
1637

86. 121
pHi
?iSOFA

88. 123
MARS
NAC
DOPEX
PgI2
TERLI
ALB

90. 125

91. 126
First dialysis (Kolff)
1945

92. 127
Int J Artif Organs. 2017 Jun; 40(6): 257–264.

93. 128
CUPRO
DOPA
LASIX
(C)RRT
AKIKI
RENAL
CITRATE
HES

96. Sepsis
Kills

97. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 132
perspective

98. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 133
Sepsis Mortality
10
15
20
25
30
35
40
45
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Australia USA

99. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 134
0
10
20
30
40
50
60
70
80
In-hospital
mortality (all
patients)
28-day mortality 60-day mortality
Standard
Therapy
EGT
2001

100. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 135
continuum

101. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 136
¨ A nonspecific insult with ³2 of
the following:
• Temp. ³38oC or £36oC
• HR ³90 beats/min
• Respirations ³20/min
• WBC ³12,000/mm3 or
£4,000/mm3 or >10%
bands
SIRS with a
presumed or
confirmed
infectious
process
Sepsis with organ failure
Refractory hypotension
Septic
Shock
Sepsis 2.0: Defining a Disease Continuum
Bone et al. Chest. 1992;101:1644
SepsisSIRSInfection Severe Sepsis

102. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 137
¨ A nonspecific insult with ³2 of
the following:
• Temp. ³38oC or £36oC
• HR ³90 beats/min
• Respirations ³20/min
• WBC ³12,000/mm3 or
£4,000/mm3 or >10%
bands
SIRS with a
presumed or
confirmed
infectious
process
Sepsis with organ failure
Refractory hypotension
Septic
Shock
Sepsis 2.0: Defining a Disease Continuum
Bone et al. Chest. 1992;101:1644
SepsisSIRSInfection Severe Sepsis
1992

103. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 138

104. Manu Malbrain Should the SSCG retire? PRO 24-10-2018 ⎮ 139
2016

105. Sepsis 3.0 =
Infection +
Organ dysfunction
Singer M et al.JAMA 2016;315(8):801-810.

106. Sepsis 3.0 =
Infection +
Organ dysfunction
Singer M et al.JAMA 2016;315(8):801-810.

108. 143

109. 144
Science
Politics
Industry
Religion

110. 145
Acid
Base
Pro-
coagulation
Anti-
coagulation
Oxidants
Anti-
oxidants
Pro-inflammation
Anti-
inflammation
Ischaemia
Reperfusion
DAMPS
PAMPS
Colloids
Crystalloids
Slide by Courtesy of Zsolt Molnar

111. 147
Hour
bundle
3
Surviving Sepsis Campaign. Hour-1 Bundle. Available at: http://www.survivingsepsis.org/Bundles/Pages/default.aspx
(accessed March 2019). Rhodes A et al. Intensive Care Med 2017;43:304-377.

112. 148
Hour
bundle
1
Apply vasopressors if patient is hypotensive
during or after fluid resuscitation to maintain
MAP ≥ 65 mm Hg
5
Surviving Sepsis Campaign. Hour-1 Bundle. Available at: http://www.survivingsepsis.org/Bundles/Pages/default.aspx
(accessed March 2019). Rhodes A et al. Intensive Care Med 2017;43:304-377.

113. 30 ml/kg/ hr?Levy MM et al. IntensiveCare Med 2018;44:925-928.

114. SEP-1 Mandate
30 ml/kg/1 hr
Levy MM et al. IntensiveCare Med 2018;44:925-928.

115. 151
Why?

116. 155 kg
YES
High court
State NY (SEP1)
Malpractice
4650 ml
in 1
hour
NO

117. Initial
ResuscitationX

118. UseVasopressors

119. Glucose Control
X

120. Bicarbonate
TherapyX

121. Antimicrobial
Bi-TherapyX

122. Blood Products
X

124. Goal Oriented
therapy
EGDT early goal
directed therapy
Combination therapy
We Like Bundles…

128. 164
STOP

130. Alice in Bundleland
(strong recommendation, low quality of evidence).
(strong recommendation, low quality of evidence).
(strong recommendation, low quality of evidence).
(strong recommendation, low quality of evidence).
(strong recommendation, low quality of evidence).
(strong recommendation, low quality of evidence).
(strong recommendation, low quality of evidence).
First 1-3 Hours
First 6 Hours
(strong recommendation, low quality of evidence).
?

131. strong recommendation
low quality of evidence

133. Incestuous amplification

135. 171

136. 172
•Measuring is knowing

137. 173

138. 174
GIPS

140. De Waele Nutrition
Monnet Hemodynamic
Reuter Pulmonary
Molnar Renal
Wilmer Hepatic
Taccone Neurologic
De Waele Intestinal

141. BRIGHT