ICU year in review - Paul Young and Flavia Machado
•
1 like•3,130 views
This tweet lists two Twitter accounts, @DogICUma and @FlaviaSepsis, that discuss critical care trials and sepsis. It suggests following these accounts to stay informed on recent important clinical research findings in critical care and sepsis.
Report
Share
Report
Share
Download to read offline
Recommended
Submassive PE should be Thrombolysed
Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE).
PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum.
Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics.
Anand argues for the use of thrombolytics.
Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time.
Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve.
Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs.
Iain takes a different approach in his reply.
Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these.
In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song!
Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell
For more like this, head to our podcast page. #CodaPodcast
A Young Person's Experience of Critical Illness
Natalie May & Roisin McNamara discuss a young person’s experience of critical illness.
They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is scary for anyone. However, when you are a young person, this terrifying experience is amplified.
Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience.
Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.
The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared.
On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.
Bringing one’s awareness to this can assist when we are deciding how and when to discuss the ongoing treatment.
Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.
Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one’s young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family.
Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.
Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable.
For more like this, head to our podcast page. #CodaPodcast
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
DNR Should Be The Default - PRO: Alex Psirides, CON: Sara Gray
The application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember - 2 weeks in ICU can spare you 5 minutes of difficult conversation.
vs.
Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often.
1455 wilson
Martin Smith
The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary or even harmful in certain patients at certain times.
Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.
The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.
Mark Wilson
The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).
Emergency Interventions: The use of Oxygen
Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.
Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.
70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.
These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.
Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.
This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.
There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.
The production of Oxygen may only happen in a few places.
Poor cylinder quality leads to leaks and therefore, low supply.
Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.
Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.
Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.
Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.
Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.
The Problem with Hospital Systems: Alex Psirides
Alex Psirides discusses the problem with major hospitals and the systems that they use.
Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.
As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.
The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.
Many staff lack acute medical skills.
Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.
Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.
Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.
Unfortunately, junior doctors often call for help when it is too late.
Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’
The Problem with Hospital Systems: Alex Psirides
For more like this, head to our podcast page. #CodaPodcast
Debate: Prehospital Doctors add little value in Trauma
Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma.
Anthony argues that doctors in the prehospital setting add little value.
He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity.
Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge.
Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves.
This leads to apples being compared to oranges most of the time.
Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics.
MJ argues for the negative.
In doing so, she concedes that the evidence base for prehospital medicine is scarce.
This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital.
This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival.
Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too.
Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration.
Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma.
For more like this, head to our podcast page. #CodaPodcast
Recommended
Submassive PE should be Thrombolysed
Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE).
PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum.
Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics.
Anand argues for the use of thrombolytics.
Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time.
Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve.
Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs.
Iain takes a different approach in his reply.
Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these.
In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song!
Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell
For more like this, head to our podcast page. #CodaPodcast
A Young Person's Experience of Critical Illness
Natalie May & Roisin McNamara discuss a young person’s experience of critical illness.
They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is scary for anyone. However, when you are a young person, this terrifying experience is amplified.
Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience.
Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.
The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared.
On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.
Bringing one’s awareness to this can assist when we are deciding how and when to discuss the ongoing treatment.
Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.
Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one’s young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family.
Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.
Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable.
For more like this, head to our podcast page. #CodaPodcast
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
DNR Should Be The Default - PRO: Alex Psirides, CON: Sara Gray
The application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember - 2 weeks in ICU can spare you 5 minutes of difficult conversation.
vs.
Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often.
1455 wilson
Martin Smith
The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary or even harmful in certain patients at certain times.
Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.
The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.
Mark Wilson
The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).
Emergency Interventions: The use of Oxygen
Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.
Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.
70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.
These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.
Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.
This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.
There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.
The production of Oxygen may only happen in a few places.
Poor cylinder quality leads to leaks and therefore, low supply.
Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.
Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.
Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.
Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.
Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.
The Problem with Hospital Systems: Alex Psirides
Alex Psirides discusses the problem with major hospitals and the systems that they use.
Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.
As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.
The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.
Many staff lack acute medical skills.
Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.
Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.
Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.
Unfortunately, junior doctors often call for help when it is too late.
Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’
The Problem with Hospital Systems: Alex Psirides
For more like this, head to our podcast page. #CodaPodcast
Debate: Prehospital Doctors add little value in Trauma
Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma.
Anthony argues that doctors in the prehospital setting add little value.
He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity.
Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge.
Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves.
This leads to apples being compared to oranges most of the time.
Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics.
MJ argues for the negative.
In doing so, she concedes that the evidence base for prehospital medicine is scarce.
This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital.
This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival.
Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too.
Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration.
Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma.
For more like this, head to our podcast page. #CodaPodcast
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
How do you diagnose death? In Critical Care we deal with death on a regular basis and although it seems black and white, that is often far from the truth.
Patricia Gerritsen discusses what it means to be dead and how that knowledge can aid you in stopping a resuscitation effort.
Patricia presents the degrees of death in her eyes as:
Soon to be dead
Reversibly dead
Irreversibly dead
Reversibly, irreversibly dead
Changes occur following death that can be proof of death. But not always. Pallor mortis, algor mortis, rigor mortis, livor mortis and decomposition can all indicate someone has died.
There are other clues that can indicate a person is either dead or will soon be dead – with minimal chance of any life saving intervention. The varying ways death presents itself poses a challenge for the clinician. This is especially true when deciding when to stop a resuscitation effort.
Consider the reversibly, irreversibly dead – also known as the Lazarus phenomenon. These patients achieve return of spontaneous circulation AFTER the resuscitation effort has been stopped. There are over 50 cases in the literature, with a wide and unpredictable array of clinical situations.
Therefore, the question becomes - what are the limits that can be survived? Patricia suggests that we must know the extreme limits in order to make an educated decision about resuscitation.
Patricia details some of the most extreme stories of survival in the literature. Submersion has been survived after 66 minutes in a child. An individual survived being in an ice stream after 40 minutes, with a recorded temperature of 13.7 degrees. A man with a potassium of 14 mmol/L made a good recovery.
There is a case of someone with a pH of 6.33 recovery fully and someone surviving a CO2 level of 375mmHg.
Patricia highlights these extreme examples to show what is possible whilst acknowledging the decision to stop resuscitation is a difficult and nuanced one.
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
For more like this, head to our podcast page. #CodaPodcast
Post-Intubation Sedation: Scott Weingart
Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis.
Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive.
How would you like a piece of plastic placed down your throat?
The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium.
In simple terms delirium leads to poor outcomes and death.
Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness.
So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated.
The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer?
Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play.
Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice.
Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation.
In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department.
Join Scott as he passionately discusses post-intubation sedation.
For more like this, head to our podcast page. #CodaPodcast
The Risks of Surgery: John Carlisle
John Carlisle asks the big question – what is the risk of surgery? It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery?
Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big.
John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current data, and the flaws in the recommendations currently being offered.
John then describes a tool he has developed relating to this particular question. The tool also explains how one piece of research has been misunderstood, a misunderstanding that has resulted in two general mistakes: surgeons operating on aneurysms when they should not; surgeons not operating on aneurysms when they should.
For more like this, head to our podcast page. #CodaPodcast
Debate: The ICU is no place for the elderly
Francesca Rubulotta argues in favour of the ICU being no place for the elderly.
She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise.
She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model.
This extends to the type of treatment required – whether it be for an acute or chronic condition.
Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly.
Francesca concludes that for the elderly, there needs to be a new model.
One reliable, dedicated to the older patient population and able to provide the dignity they deserve.
Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare.
‘Elderly’ is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right ‘elderly’ patient.
Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care.
Karin suggests this is discrimination.
For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate.
Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly.
For more like this, head to our podcast page. #CodaPodcast
Is Point of Care Ultrasound (POCUS) a problem?
Maxime Valois and John Christian Fox argue the role of POCUS in critical care.
Maxime makes the case for POCUS being a problem.
POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses.
It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common.
Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology.
Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism.
This has been the case of all past scientific revolutions.
Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem.
John on the other hand claims in no way is POCUS a problem.
It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web.
John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation.
Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients.
John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine.
Is Point of Care Ultrasound (POCUS) a problem?
For more like this, head to our podcast page. #CodaPodcast
Biomarkers in Emergency Medicine: Katrin Hruska
Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.
All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.
In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.
A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001).
This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time).
If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.
As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system.
In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low.
Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low.
There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
How to manage conflict in Critical Care: Ronan O’Leary
In this entertaining talk, Ronan O’Leary discusses conflict in critical care.
Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy.
Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care.
Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don’t know when, or even how.
Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play.
Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches?
Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either.
An important component will be the future structure of clinical training. Our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts.
Ronan posits that training should involve exposure to collegiate decision making and consensus building.
However, this will be difficult to achieve within our current nationally co-ordinated training schemes.
For more like this, head to our podcast page. #CodaPodcast
Cardiac Arrest and Oxygen: Stephen Bernard
Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients.
Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes.
This is especially true in hospitals where oxygen is used frequently and often without much thought.
Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea.
In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest.
Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge.
The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way.
Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury.
Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.
Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
Ultrasound Improves Resuscitation Outcomes: Resa Lewiss
Resa Lewis tells you how ultrasound improves resuscitation outcomes in critical care.
Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient.
However, there may be more to ultrasound - Resa enlightens you.
The ultrasound allows the clinician to interact with their patients.
Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity.
Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.
Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes.
Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this.
Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients.
Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient’s overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.
Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves.
For more like this, head to our podcast page. #CodaPodcast
Disaster Ethics in Critical Care: Sara Gray
Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed.
Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster.
Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what?
Sara discusses her guiding principles when thinking about disaster triage.
First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available.
The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people.
Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being “sprung” on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans.
Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government.
It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job.
Finally, for more like this, head to our podcast page. #CodaPodcast
Burnout in Healthcare: Peter Brindley
Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes.
Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism.
Moreover, burnout involves the 4 C's: cutting corners, cynicism, callousness, and contempt.
Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, “this is not what I signed up for.”
Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout.
Peter suggests a few things that we can do to prevent burnout. He recommends purposeful imbalance and dividing career into thirds: learning, earning, and returning.
Evidently, burnout is a chronic condition, and although it cannot be cured, it is manageable. It might take years to manifest and hence, we must always be on the lookout for the signs.
Finally, for more like this head to our podcast page. #CodaPodcast
Critical Care: No place for a woman?
Ah, but you don't look like a professor! A recent statement from a (female) patient says it all, doesn't it?
Since the first women were admitted to medical schools – quite a while ago in most countries, the participation of women in clinical and academic medicine has increased steadily. Overall, women represent the majority of health care workers and also medical students in most countries of the world today. SMACC audience is almost 50% female.
However, only few women make it to the top, and with each step up the career ladder, the proportion of women decreases substantially, a phenomenon called the “glass ceiling” or the „leaky pipeline“. This is particularly true for some medical specialties such as critical care or trauma surgery, as opposed to specialties like endocrinology, pediatrics or gynecology. Although often subtle, gender discrimination against women continues to be a problem – for instance, it has been shown that a ficticious student named “John” would receive a higher salary and find a mentor easier than “Jennifer”. A manuscript written by “John” is judged more favourably than one that is authored by “Joan”, and female grant applicants with the same scientific productivity are given substantially lower scores than male applicants by reviewers (men and women). Sheryl Sandberg’s statements are as true in clinical and academic medicine as in other areas.
This talk will definitely raise your awareness for the topic.
Anaesthetics in Bariatric Surgery: Ben Shippey
Ben Shippey discusses the important anaesthetic considerations in bariatric surgery. Obesity surgery can induce a strong response in healthcare professionals.
These biases must be overcome to facilitate efficient and safe services. Evidently, Bariatric surgery provides many challenges.
To begin with, healthcare professionals can associate negative thoughts with obesity.
Secondly, these patients present complex respiratory and cardiovascular physiology that must be considered.
Ben highlights three important considerations when preparing for, and delivery anaesthetics in the bariatric population. These are Attitude, Assessment and Act.
Attitude -
Encompasses the attitude of the physicians, theatre team and the patient themselves. One must recognise and change their thinking about the obese patient. Ben’s team does this by realising the complex psychological background these patients invariably have.
Assessment -
Furthermore, a multidisciplinary team must undertake a broad assessment.
Specifically for the anaesthetic team, there is a complex decision pathway, especially with managing the airway. The broad principle should be to shorten the time between the awake, vertical, spontaneously breathing obese person and the supine, anaesthetised, intubated and positively pressure ventilated patient.
Finally, Act -
As Ben states, the previous two points are null and void if it does not change practice. The key element to act is to plan! This involves having a clear action plan for the intubation of the patient and failing that, clear points at which Plan B, C and D will be initiated.
He encourages his theatre staff to alert him when a cut off Sp02 is reached so he can move to the next course of action. He comes prepared - for example, by having the cricothyroid membrane marked out.
Furthermore, it is important to consider putting the patient to sleep and waking them up. As Ben puts it – pay attention to the take off as well as the landing!
Lastly, the post-operative care is significantly important. Remember patient positioning in bed (not slumped) and encourage early mobilisation.
These patients need to be up and moving, as well as having the appropriate DVT prophylaxis in place. The obese patient presents unique challenges to the anaesthetist.
Anaesthetics in Bariatric Surgery: Ben Shippey
For more like this, head to our podcast page. #CodaPodcast
Transfusion Thresholds in Acute Brain Injury
A bare knuckle pit fight between Oli Flower & Simon Finfer over when to transfuse in acute brain injury...
Oli argues that the transfusion threshold should be 90 g/L, whereas Simon takes 70 g/L to be a more appropriate trigger to transfuse blood in the context of acute brain injury.
The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives crit care professionals mad - surely there must be a ""right"" number. Unfortunately there isn't, which is where understanding all the relevant aspects to the argument becomes important.
Enjoy listening to these two duke it out and then make up your mind - what will your number be?
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
In this podcast, Mervyn Singer talks about the link between stress and multiple organ failure.
Often, the organs involved in multi-organ failure show no signs of structural damage or cell damage that would indicate these organs might be under stress. Stress might cause functional damage rather than structural damage.
Stress is a normal coping mechanism which helps to deal with the various stressors we encounter. These mechanisms include changes in behaviour, as well as autonomic and hormonal modulation of various systems. These include inflammatory, immune, cardiovascular, respiratory and metabolic systems.
Human bodies are not designed to cope with the stresses of prolonged life. These stresses include old age, co-morbidities, prolonged critical illness, modern lifesaving drugs, and organ support.
Mervyn discusses the evolution of various theories associated with stress.
Walter Cannon discovered acute stress response in 1915 when he noticed the manifestation of nervous exhaustion as physical illness in soldiers of World War I.
Furthermore, Hans Seyle described the general adaptation syndrome in 1936, stating that when in distress, the physiological systems are functionally compromised.
Moreover, Takotsubo identified cardiomyopathy in the early 90s in Japan – in this condition heart failure occurs due to emotional stress.
Ultimately, Sterling and Eyer defined Allostasis in 1988 as "staying the same by being different." The body goes into allostatic overload when exposed to extreme stress conditions. Type 1 allostatic overload of stress causes the organism to switch off in order to regain energy balance. Hibernation, estivation, anoxia, and dormancy are all example of allostatic response to stress. Myocardial hibernation is an example of an allostatic response in humans.
Multiple markers identify poor prognosis in stressed patients. Energy and metabolism are directly proportional to each other and a reduced level of either or both can be seen in critically stressed patients.
An ICU patient is under multiple stressors. These include physiological, pharmacological, environmental, and psychological stress, all of which lead to chronic critical illnesses.
Thus, multiple organ failure may be an allostatic response to the prolonged stress faced by an ICU patient.
Mervyn ends the podcast by suggesting multiple pharmacological and non-pharmacological methods to de-stress the patients.
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
For more like this, head to our podcast page. #CodaPodcast
CSD by Jeffcote Coda 22.pdf
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Subdural Haemorrhage and MMA embolisation
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
The BONANZA Trial and PbTO2 Monitoring
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
Dilating the Dogma of Vasospasm
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
EVD Tips and Tricks
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
More Related Content
Viewers also liked
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
How do you diagnose death? In Critical Care we deal with death on a regular basis and although it seems black and white, that is often far from the truth.
Patricia Gerritsen discusses what it means to be dead and how that knowledge can aid you in stopping a resuscitation effort.
Patricia presents the degrees of death in her eyes as:
Soon to be dead
Reversibly dead
Irreversibly dead
Reversibly, irreversibly dead
Changes occur following death that can be proof of death. But not always. Pallor mortis, algor mortis, rigor mortis, livor mortis and decomposition can all indicate someone has died.
There are other clues that can indicate a person is either dead or will soon be dead – with minimal chance of any life saving intervention. The varying ways death presents itself poses a challenge for the clinician. This is especially true when deciding when to stop a resuscitation effort.
Consider the reversibly, irreversibly dead – also known as the Lazarus phenomenon. These patients achieve return of spontaneous circulation AFTER the resuscitation effort has been stopped. There are over 50 cases in the literature, with a wide and unpredictable array of clinical situations.
Therefore, the question becomes - what are the limits that can be survived? Patricia suggests that we must know the extreme limits in order to make an educated decision about resuscitation.
Patricia details some of the most extreme stories of survival in the literature. Submersion has been survived after 66 minutes in a child. An individual survived being in an ice stream after 40 minutes, with a recorded temperature of 13.7 degrees. A man with a potassium of 14 mmol/L made a good recovery.
There is a case of someone with a pH of 6.33 recovery fully and someone surviving a CO2 level of 375mmHg.
Patricia highlights these extreme examples to show what is possible whilst acknowledging the decision to stop resuscitation is a difficult and nuanced one.
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
For more like this, head to our podcast page. #CodaPodcast
Post-Intubation Sedation: Scott Weingart
Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis.
Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive.
How would you like a piece of plastic placed down your throat?
The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium.
In simple terms delirium leads to poor outcomes and death.
Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness.
So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated.
The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer?
Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play.
Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice.
Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation.
In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department.
Join Scott as he passionately discusses post-intubation sedation.
For more like this, head to our podcast page. #CodaPodcast
The Risks of Surgery: John Carlisle
John Carlisle asks the big question – what is the risk of surgery? It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery?
Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big.
John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current data, and the flaws in the recommendations currently being offered.
John then describes a tool he has developed relating to this particular question. The tool also explains how one piece of research has been misunderstood, a misunderstanding that has resulted in two general mistakes: surgeons operating on aneurysms when they should not; surgeons not operating on aneurysms when they should.
For more like this, head to our podcast page. #CodaPodcast
Debate: The ICU is no place for the elderly
Francesca Rubulotta argues in favour of the ICU being no place for the elderly.
She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise.
She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model.
This extends to the type of treatment required – whether it be for an acute or chronic condition.
Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly.
Francesca concludes that for the elderly, there needs to be a new model.
One reliable, dedicated to the older patient population and able to provide the dignity they deserve.
Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare.
‘Elderly’ is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right ‘elderly’ patient.
Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care.
Karin suggests this is discrimination.
For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate.
Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly.
For more like this, head to our podcast page. #CodaPodcast
Is Point of Care Ultrasound (POCUS) a problem?
Maxime Valois and John Christian Fox argue the role of POCUS in critical care.
Maxime makes the case for POCUS being a problem.
POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses.
It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common.
Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology.
Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism.
This has been the case of all past scientific revolutions.
Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem.
John on the other hand claims in no way is POCUS a problem.
It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web.
John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation.
Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients.
John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine.
Is Point of Care Ultrasound (POCUS) a problem?
For more like this, head to our podcast page. #CodaPodcast
Biomarkers in Emergency Medicine: Katrin Hruska
Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.
All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.
In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.
A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001).
This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time).
If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.
As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system.
In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low.
Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low.
There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
How to manage conflict in Critical Care: Ronan O’Leary
In this entertaining talk, Ronan O’Leary discusses conflict in critical care.
Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy.
Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care.
Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don’t know when, or even how.
Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play.
Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches?
Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either.
An important component will be the future structure of clinical training. Our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts.
Ronan posits that training should involve exposure to collegiate decision making and consensus building.
However, this will be difficult to achieve within our current nationally co-ordinated training schemes.
For more like this, head to our podcast page. #CodaPodcast
Cardiac Arrest and Oxygen: Stephen Bernard
Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients.
Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes.
This is especially true in hospitals where oxygen is used frequently and often without much thought.
Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea.
In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest.
Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge.
The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way.
Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury.
Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.
Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
Ultrasound Improves Resuscitation Outcomes: Resa Lewiss
Resa Lewis tells you how ultrasound improves resuscitation outcomes in critical care.
Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient.
However, there may be more to ultrasound - Resa enlightens you.
The ultrasound allows the clinician to interact with their patients.
Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity.
Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.
Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes.
Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this.
Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients.
Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient’s overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.
Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves.
For more like this, head to our podcast page. #CodaPodcast
Disaster Ethics in Critical Care: Sara Gray
Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed.
Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster.
Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what?
Sara discusses her guiding principles when thinking about disaster triage.
First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available.
The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people.
Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being “sprung” on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans.
Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government.
It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job.
Finally, for more like this, head to our podcast page. #CodaPodcast
Burnout in Healthcare: Peter Brindley
Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes.
Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism.
Moreover, burnout involves the 4 C's: cutting corners, cynicism, callousness, and contempt.
Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, “this is not what I signed up for.”
Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout.
Peter suggests a few things that we can do to prevent burnout. He recommends purposeful imbalance and dividing career into thirds: learning, earning, and returning.
Evidently, burnout is a chronic condition, and although it cannot be cured, it is manageable. It might take years to manifest and hence, we must always be on the lookout for the signs.
Finally, for more like this head to our podcast page. #CodaPodcast
Critical Care: No place for a woman?
Ah, but you don't look like a professor! A recent statement from a (female) patient says it all, doesn't it?
Since the first women were admitted to medical schools – quite a while ago in most countries, the participation of women in clinical and academic medicine has increased steadily. Overall, women represent the majority of health care workers and also medical students in most countries of the world today. SMACC audience is almost 50% female.
However, only few women make it to the top, and with each step up the career ladder, the proportion of women decreases substantially, a phenomenon called the “glass ceiling” or the „leaky pipeline“. This is particularly true for some medical specialties such as critical care or trauma surgery, as opposed to specialties like endocrinology, pediatrics or gynecology. Although often subtle, gender discrimination against women continues to be a problem – for instance, it has been shown that a ficticious student named “John” would receive a higher salary and find a mentor easier than “Jennifer”. A manuscript written by “John” is judged more favourably than one that is authored by “Joan”, and female grant applicants with the same scientific productivity are given substantially lower scores than male applicants by reviewers (men and women). Sheryl Sandberg’s statements are as true in clinical and academic medicine as in other areas.
This talk will definitely raise your awareness for the topic.
Anaesthetics in Bariatric Surgery: Ben Shippey
Ben Shippey discusses the important anaesthetic considerations in bariatric surgery. Obesity surgery can induce a strong response in healthcare professionals.
These biases must be overcome to facilitate efficient and safe services. Evidently, Bariatric surgery provides many challenges.
To begin with, healthcare professionals can associate negative thoughts with obesity.
Secondly, these patients present complex respiratory and cardiovascular physiology that must be considered.
Ben highlights three important considerations when preparing for, and delivery anaesthetics in the bariatric population. These are Attitude, Assessment and Act.
Attitude -
Encompasses the attitude of the physicians, theatre team and the patient themselves. One must recognise and change their thinking about the obese patient. Ben’s team does this by realising the complex psychological background these patients invariably have.
Assessment -
Furthermore, a multidisciplinary team must undertake a broad assessment.
Specifically for the anaesthetic team, there is a complex decision pathway, especially with managing the airway. The broad principle should be to shorten the time between the awake, vertical, spontaneously breathing obese person and the supine, anaesthetised, intubated and positively pressure ventilated patient.
Finally, Act -
As Ben states, the previous two points are null and void if it does not change practice. The key element to act is to plan! This involves having a clear action plan for the intubation of the patient and failing that, clear points at which Plan B, C and D will be initiated.
He encourages his theatre staff to alert him when a cut off Sp02 is reached so he can move to the next course of action. He comes prepared - for example, by having the cricothyroid membrane marked out.
Furthermore, it is important to consider putting the patient to sleep and waking them up. As Ben puts it – pay attention to the take off as well as the landing!
Lastly, the post-operative care is significantly important. Remember patient positioning in bed (not slumped) and encourage early mobilisation.
These patients need to be up and moving, as well as having the appropriate DVT prophylaxis in place. The obese patient presents unique challenges to the anaesthetist.
Anaesthetics in Bariatric Surgery: Ben Shippey
For more like this, head to our podcast page. #CodaPodcast
Transfusion Thresholds in Acute Brain Injury
A bare knuckle pit fight between Oli Flower & Simon Finfer over when to transfuse in acute brain injury...
Oli argues that the transfusion threshold should be 90 g/L, whereas Simon takes 70 g/L to be a more appropriate trigger to transfuse blood in the context of acute brain injury.
The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives crit care professionals mad - surely there must be a ""right"" number. Unfortunately there isn't, which is where understanding all the relevant aspects to the argument becomes important.
Enjoy listening to these two duke it out and then make up your mind - what will your number be?
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
In this podcast, Mervyn Singer talks about the link between stress and multiple organ failure.
Often, the organs involved in multi-organ failure show no signs of structural damage or cell damage that would indicate these organs might be under stress. Stress might cause functional damage rather than structural damage.
Stress is a normal coping mechanism which helps to deal with the various stressors we encounter. These mechanisms include changes in behaviour, as well as autonomic and hormonal modulation of various systems. These include inflammatory, immune, cardiovascular, respiratory and metabolic systems.
Human bodies are not designed to cope with the stresses of prolonged life. These stresses include old age, co-morbidities, prolonged critical illness, modern lifesaving drugs, and organ support.
Mervyn discusses the evolution of various theories associated with stress.
Walter Cannon discovered acute stress response in 1915 when he noticed the manifestation of nervous exhaustion as physical illness in soldiers of World War I.
Furthermore, Hans Seyle described the general adaptation syndrome in 1936, stating that when in distress, the physiological systems are functionally compromised.
Moreover, Takotsubo identified cardiomyopathy in the early 90s in Japan – in this condition heart failure occurs due to emotional stress.
Ultimately, Sterling and Eyer defined Allostasis in 1988 as "staying the same by being different." The body goes into allostatic overload when exposed to extreme stress conditions. Type 1 allostatic overload of stress causes the organism to switch off in order to regain energy balance. Hibernation, estivation, anoxia, and dormancy are all example of allostatic response to stress. Myocardial hibernation is an example of an allostatic response in humans.
Multiple markers identify poor prognosis in stressed patients. Energy and metabolism are directly proportional to each other and a reduced level of either or both can be seen in critically stressed patients.
An ICU patient is under multiple stressors. These include physiological, pharmacological, environmental, and psychological stress, all of which lead to chronic critical illnesses.
Thus, multiple organ failure may be an allostatic response to the prolonged stress faced by an ICU patient.
Mervyn ends the podcast by suggesting multiple pharmacological and non-pharmacological methods to de-stress the patients.
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
For more like this, head to our podcast page. #CodaPodcast
Viewers also liked (15)
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
How to manage conflict in Critical Care: Ronan O’Leary
How to manage conflict in Critical Care: Ronan O’Leary
Ultrasound Improves Resuscitation Outcomes: Resa Lewiss
Ultrasound Improves Resuscitation Outcomes: Resa Lewiss
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
Stress Metabolism Adaptation & Critical Illness: Mervyn Singer
More from SMACC Conference
CSD by Jeffcote Coda 22.pdf
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Subdural Haemorrhage and MMA embolisation
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
The BONANZA Trial and PbTO2 Monitoring
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
Dilating the Dogma of Vasospasm
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
EVD Tips and Tricks
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories work
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
TBI: when to stop and when to give time
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Ketamine in Brain Injury by Toby Jeffcote
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne Lee
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
EEG and Status Eplilepticus by Tania Farrar
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Browne Neuro symposium.pptx
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Paediatric Stroke by Shree Basu
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?
After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference.
Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways.
Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions.
Hypertensive therapy is relatively safe and easy to implement but not without risk.
Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.
Optimal Cerebral Perfusion Pressure
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
The Power of Words - Death and Language.ppt
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.
Brain injury outcomes and predictors
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
More from SMACC Conference (20)
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill - More neuroanatomy pearls for neurocritical care
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
TBI Debate - Mild, moderate and severe categories work
TBI Debate - Mild, moderate and severe categories work
Managing Complications of Chronic SCI by Bonne Lee
Managing Complications of Chronic SCI by Bonne Lee
Hypertensing Spinal Cord Injury - gold standard or wacky?
Hypertensing Spinal Cord Injury - gold standard or wacky?
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Recently uploaded
micro teaching on communication m.sc nursing.pdf
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Dehradun #ℂall #gIRLS Oyo Hotel 9719300533 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 9719300533 #ℂall #gIRL in Dehradun
Light House Retreats: Plant Medicine Retreat Europe
Our aim is to organise conscious gatherings and retreats for open and inquisitive minds and souls, with and without the assistance of sacred plants.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
PPT RELATED TO ARTHROLOGY ACCORDING TO NCISM AYURVEDA
Effective-Soaps-for-Fungal-Skin-Infections.pptx
Swisschem Dermacare has mentioned the List of The Best Antifungal Soap In India 2022. All of these soaps are trusted by various Dermatology Experts.
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
Valuable Content of Human Anatomy and Physiology of Urinary system as per PCI Syllabus for Pharmacy and PharmD Students.
Best Ayurvedic medicine for Gas and Indigestion
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Physiology of Chemical Sensation of smell.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Top-Vitamin-Supplement-Brands-in-India.pptx
Swisschem Dermacare provides the Top 10 Vitamin Supplement Brands in India. To know more about us give us call at our official number
Top 10 Best Ayurvedic Kidney Stone Syrups in India
we have mentioned the best 10 ayurvedic Kidney Stone Syrups. You can check all these products and choose the best one for yourself.
Knee anatomy and clinical tests 2024.pdf
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
The Electrocardiogram - Physiologic Principles
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Drug Discovery and Development .....
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recently uploaded (20)
Dehradun #ℂall #gIRLS Oyo Hotel 9719300533 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 9719300533 #ℂall #gIRL in Dehradun
Light House Retreats: Plant Medicine Retreat Europe
Light House Retreats: Plant Medicine Retreat Europe
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Top 10 Best Ayurvedic Kidney Stone Syrups in India
Top 10 Best Ayurvedic Kidney Stone Syrups in India
ICU year in review - Paul Young and Flavia Machado
- 1. The top 10 critical care trials of the recent past... @DogICUma & @FlaviaSepsis