How to manage conflict in Critical Care: Ronan O’Leary
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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
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Controversies in Brain Death
Martin Smith persuades you that controversies in brain death should not, and do not, exist.
Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification.
Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain.
Martin provides a history of the concept of brain death. He describes how advances in modern medicine have made the concept of death, and specifically brain death, muddled. This has broad implications on the diagnosis of brain death – and provides the basis to the controversies that exist.
The concept of death as a process is explored.
The idea, and in fact the truth, is that death does not happen at a discrete moment in time.
Alive or dead may be the only two states an organism can be in. However, the transition from one to the other is not instantaneous.
Martin contends that the process and the nomenclature has little practical relevance. What is important is the point of irreversibility.
He explains how we, as a medical community, can be confident of this point.
The main points are 1) fulfilment of essential preconditions, 2) exclusions of reversible causes and 3) clinical evaluation.
In his talk Martin elaborates on each and provides some important teaching points. As he explains, this is an important concept to grasp as it has implications for your patients as well as broader societal implications in the context of organ donation.
Martin’s talk will discuss the history and development of the concepts and diagnosis of brain death internationally. He examines current challenges and controversies and makes the case for an international consensus.
For more like this, head to our podcast page. #CodaPodcast
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care.
These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L.
He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups.
Simon continues by raising further research to justify his position.
Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does!
As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue.
Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad.
So surely there must be a “right” number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important.
Join Oli and Simon as they debate on this important issue.
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
For more like this, head to our podcast page. #CodaPodcast
Neonatal and Paediatric Retrieval: Hazel Talbot
Hazel Talbot gives her insights from working in neonatal and paediatric retrieval.
She delivers her talk with all the passion and dedication that she brings to her work as a neonatal and paediatric transport consultant.
Equipment failure, rapidly deteriorating children and miscommunication are all common challenges that Hazel and her team encounter in their line of work. This is on top of the challenge of caring for neonates and children.
How are children different? They differ in physiology, in disease profiles and even the way they make clinicians feel!
In this talk, Hazel focuses on physiology and disease. The large majority of young deaths in the UK, where Hazel works, are neonates – under 28 days old.
50% of these deaths are due to perinatal diseases. These include congenital malformations, prematurity, sepsis, and congenital heart conditions.
Children are small adults. Small airways, small necks, small lungs. Babies however are not small children. They use the majority of their physiological ability to survive.
When they breath they use most of their diaphragm, compared with an adult who will only use a small proportion. This leaves babies without much reserve. They have a high metabolic rate, and neonates have a right heart dominance with an inability to change their stroke volume.
Hazel urges you to consider this when faced with a sick baby. When thinking about neonatal and paediatric retrieval, Hazel has some key points. Practice, anticipation and knowing your environment and equipment is key to a success outcome.
Hazel drives this message home with a case presentation. This example highlights not only Hazel’s skill and knowledge, but also her ability of communication, leadership, and intuition.
Join Hazel as she gives an insight into her amazing work in neonatal and paediatric retrieval. Come along as she discusses her experiences and tells you how to ward of the Evil Transport Fairy!
For more like this, head to our podcast page. #CodaPodcast
Orford - iValidate: Improving End of Life Care in the ICU
Associate Professor Neil Orford is an intensive care specialist and Director of Intensive Care at University Hospital Geelong. Neil is the clinical lead for the i-Validate program. In this podcast he discusses this collaboration between Barwon Health and Deakin University which aims to improve patient-centred end-of-life care through training in clinical communication.
Paed-Iconoclasm: Breaking the Myths without Breaking Your Patient
Myths and medical dogma fill the gap between what we know and what we don’t know. Learn “Defense Against the Dark Arts” and how not to let this gap hurt some of our most vulnerable patients -- children.
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
How to Spot the Sick Child in the Emergency Department
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
Ffion breaks her thinking into two main areas: physiology and psychology.
Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.
Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.
Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.
Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.
Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.
Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.
For more like this, head to our podcast page. #CodaPodcast
Recommended
Controversies in Brain Death
Martin Smith persuades you that controversies in brain death should not, and do not, exist.
Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification.
Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain.
Martin provides a history of the concept of brain death. He describes how advances in modern medicine have made the concept of death, and specifically brain death, muddled. This has broad implications on the diagnosis of brain death – and provides the basis to the controversies that exist.
The concept of death as a process is explored.
The idea, and in fact the truth, is that death does not happen at a discrete moment in time.
Alive or dead may be the only two states an organism can be in. However, the transition from one to the other is not instantaneous.
Martin contends that the process and the nomenclature has little practical relevance. What is important is the point of irreversibility.
He explains how we, as a medical community, can be confident of this point.
The main points are 1) fulfilment of essential preconditions, 2) exclusions of reversible causes and 3) clinical evaluation.
In his talk Martin elaborates on each and provides some important teaching points. As he explains, this is an important concept to grasp as it has implications for your patients as well as broader societal implications in the context of organ donation.
Martin’s talk will discuss the history and development of the concepts and diagnosis of brain death internationally. He examines current challenges and controversies and makes the case for an international consensus.
For more like this, head to our podcast page. #CodaPodcast
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care.
These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L.
He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups.
Simon continues by raising further research to justify his position.
Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does!
As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue.
Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad.
So surely there must be a “right” number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important.
Join Oli and Simon as they debate on this important issue.
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
For more like this, head to our podcast page. #CodaPodcast
Neonatal and Paediatric Retrieval: Hazel Talbot
Hazel Talbot gives her insights from working in neonatal and paediatric retrieval.
She delivers her talk with all the passion and dedication that she brings to her work as a neonatal and paediatric transport consultant.
Equipment failure, rapidly deteriorating children and miscommunication are all common challenges that Hazel and her team encounter in their line of work. This is on top of the challenge of caring for neonates and children.
How are children different? They differ in physiology, in disease profiles and even the way they make clinicians feel!
In this talk, Hazel focuses on physiology and disease. The large majority of young deaths in the UK, where Hazel works, are neonates – under 28 days old.
50% of these deaths are due to perinatal diseases. These include congenital malformations, prematurity, sepsis, and congenital heart conditions.
Children are small adults. Small airways, small necks, small lungs. Babies however are not small children. They use the majority of their physiological ability to survive.
When they breath they use most of their diaphragm, compared with an adult who will only use a small proportion. This leaves babies without much reserve. They have a high metabolic rate, and neonates have a right heart dominance with an inability to change their stroke volume.
Hazel urges you to consider this when faced with a sick baby. When thinking about neonatal and paediatric retrieval, Hazel has some key points. Practice, anticipation and knowing your environment and equipment is key to a success outcome.
Hazel drives this message home with a case presentation. This example highlights not only Hazel’s skill and knowledge, but also her ability of communication, leadership, and intuition.
Join Hazel as she gives an insight into her amazing work in neonatal and paediatric retrieval. Come along as she discusses her experiences and tells you how to ward of the Evil Transport Fairy!
For more like this, head to our podcast page. #CodaPodcast
Orford - iValidate: Improving End of Life Care in the ICU
Associate Professor Neil Orford is an intensive care specialist and Director of Intensive Care at University Hospital Geelong. Neil is the clinical lead for the i-Validate program. In this podcast he discusses this collaboration between Barwon Health and Deakin University which aims to improve patient-centred end-of-life care through training in clinical communication.
Paed-Iconoclasm: Breaking the Myths without Breaking Your Patient
Myths and medical dogma fill the gap between what we know and what we don’t know. Learn “Defense Against the Dark Arts” and how not to let this gap hurt some of our most vulnerable patients -- children.
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
How to Spot the Sick Child in the Emergency Department
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
Ffion breaks her thinking into two main areas: physiology and psychology.
Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.
Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.
Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.
Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.
Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.
Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.
For more like this, head to our podcast page. #CodaPodcast
The Problem of Disproportionate Critical Care
Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis.
Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care.
Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism.
Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries.
Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable.
Francesca discusses various studies that look at the appropriateness of care in ICU.
She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care.
We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time.
There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty.
Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU.
According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour.
For more like this, head to our podcast page. #CodaPodcast
Understanding Lactate - Paul Marik
Lactate has been viewed as a byproduct of anaerobic metabolism and an indicator of tissue hypoperfusion since the 1900s. This theory is still widely believed. Paul busts the myths surrounding lactic acidosis, anaerobic metabolism, tissue hypoxia and the role of lactate in sepsis.
Key take-away facts include:
- The production of lactate actually consumes hydrogen ions. Lactic acidosis is really lactic alkalosis.
- Lactate is produced physiologically and is a precursor for gluconeogenesis.
- During exercise, skeletal muscle exports lactate as the primary fuel for the heart and brain.
- At VO2max, intracellular oxygen stays the same. Anaerobic metabolism in cells only occur as a pre-terminal event. The exception is in complete arterial occlusion.
- Adrenaline promotes lactate production
- Lactate infusion has been shown to increase cardiac output in septic and cardiogenic shock
- Lactate is a survival advantage!
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.
Learning from excellence in critical care
Adrian Plunkett describes how to learn from excellence in critical care. Learning from excellence is an initiative which began at Birmingham Children’s Hospital.
Firstly, Adrian shares an anecdote regarding how the initiative begun. He sent a letter to the CEO of a hospital appreciating one of the doctors who treated him for cancer. The doctor unfortunately never received it. This caused Adrian to ask - is appreciation and gratitude undervalued?
Evidently, noticing excellence will lead to two things: learning new insights and increasing staff morale.
Adrian raises the question, why we do we not focus on the good things? We spend all our time improving safety and quality even though accidents and disasters are only a small percentage of what we do.
Moreover, Adrian claims that people inherently have negative biases. This is evident in healthcare, so how can we combat this?
The solution is to focus on excellent care. This led to the formation of a reporting system called Learning from Excellence (LfE), where people answer two questions: Who did something excellent? What did they do?
LfE is a formal system for reporting and providing positive feedback and appreciation to the healthcare workers. It is a beneficial and constructive way of learning from excellence.
Finally, Adrian explains, “Saying ‘thank you’ or ‘well done’ is the easiest quality improvement intervention of all.”
Learning from excellence in critical care by Adrian Plunkett
For more like this head to our podcast page. #CodaPodcast
The Broken Heart by Pete McCanny
Pete McCanny gives a talk on the cutting edge management of cardiogenic shock and challenges the conventional approach to mechanical support.
ICU year in review - Paul Young and Flavia Machado
Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.
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).
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
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?
Biomarkers in Critical Care: Mervyn Singer
Mervyn Singer discusses the use of biomarkers in critical care.
Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED.
These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth!
Prognostication can happen as early as the Emergency Department.
Studies from the States have found high levels of inflammatory cytokines can predict death, separately from clinical presentation. Therefore, we can predict when critically ill patients are destined to die. So, does this mean that we are just prolonging the life of those destined to die in critical care? Perhaps.
Mervyn discusses this being the possible reason for many failed ICU studies. Concurrently, the only progress in critical care in the past 20 years may be due only to less iatrogenic harm.
Furthermore, he explains his experiments with rats demonstrating the use of cardiovascular parameters, cytokines, troponins and even cholesterol being accurate prognostic biomarkers.
Then, Mervyn goes on to identify the use of steroids in sepsis. He talks about research that demonstrates a benefit to steroid use, but only in those patients predicted to die using the aforementioned biomarkers. This could be a key to selecting an appropriate patient group to allocate a specific treatment too.
Furthermore, we examine treating sepsis with beta blockers. Giving beta blockers to everyone has no effect at best and a harmful effect at worst. However, giving beta-blockers to those who were predicted to die conferred benefit!
In conclusion, we can predict outcome early in disease. This may allow better selection of patients for certain treatments! We thus need to adopt a completely different strategy for such patients predetermined to die. This also applies to trial design, especially where survival is the endpoint.
For more like this, head to our podcast page. #CodaPodcast
The Role of Love in Critical Care Leadership: Liz Crowe
The Role of Love in Critical Care Leadership by Liz Crowe.
There are times when this job can leave you heartbroken and love gets you through.
Bernard - Refractory Cardiac Arrest
Professor Stephen Bernard is an Intensive Care Physician at The Alfred Hospital and Medical Advisor to Ambulance Victoria. His research interests include the use of therapeutic hypothermia for the treatment of neurological injury after resuscitation from out-of hospital cardiac arrest. Here he provides a presentation on recent advances in the management of refractory cardiac arrest in the out of hospital setting.
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
The Use of Inhaled Nitric Oxide in Critical Care: Per P. Bredmose
Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient.
iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient.
Furthermore, it can be useful in both pre-hospital and in hospital care.
What is nitric oxide?
It is an endothelial derived potent short acting vasodilator mainly found in the pulmonary system. It also exists in other areas of the body. When nitric oxide is delivered via the inhaled route it has local effects only, with no systemic effects.
Most people will be familiar with the use of iNO in persistent pulmonary hypertension of the newborn.
However, there are other uses which are more “off label”. For instance, take the case of severe ARDS lungs in pre-hospital settings. These patients present challenges in retrieval for several reasons, including the retrieval ventilation systems being inferior when compared to hospital systems.
Of course, you could turn straight to ECMO. However, setting up ECMO takes time and is complex. It requires a large amount of equipment, skilled operators, and room. Nitric oxide can act as a bridge.
Per stresses, iNO is a tool to get the patient to the right place.
Nitric oxide is simple to use. It is an extra gas that goes into the ventilatory circuit. It is accessible, can be used in any vehicle, is easy to transport, and fast to grab and use. Much faster than a big ECMO set up or retrieval.
A lot of places have stopped using iNO and it has gained something of a bad reputation. The main reason for deleterious effects appears to be kidney injury. Per posits that this may be due to an increased length of time using the drug. Therefore, he advises caution.
Per concludes by explaining other conditions where iNO may be used as an adjunct to standard therapy. These situations include pulmonary hypertension, non-thrombotic pulmonary vasoconstriction, and pulmonary emboli.
Join Per Bredmose as he discusses all things inhaled nitric oxide.
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
A Patient Navigation Program for Increasing Colorectal Cancer Screening Rates
A Patient Navigation Program for Increasing Colorectal Cancer Screening RatesLeonard Davis Institute of Health Economics
Internal Medicine Board Review - Oncology Flashcards - by Knowmedge
Internal Medicine Board Review Flashcards - This eBook contains 50 Oncology Flashcards. The Flashcards are review questions and can be used to study for medical board exams including the USMLE Step Exams and the ABIM Internal Medicine Exam. More questions can be found at www.knowmedge.com
Contrarian views on coronavirus
Here's a collection of some of my LinkedIn Posts on the Coronavirus Pandemic.
I don't claim to be an expert - but do try to think logically as a doctor, and use my common sense to reason !
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The Problem of Disproportionate Critical Care
Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis.
Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care.
Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism.
Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries.
Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable.
Francesca discusses various studies that look at the appropriateness of care in ICU.
She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care.
We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time.
There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty.
Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU.
According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour.
For more like this, head to our podcast page. #CodaPodcast
Understanding Lactate - Paul Marik
Lactate has been viewed as a byproduct of anaerobic metabolism and an indicator of tissue hypoperfusion since the 1900s. This theory is still widely believed. Paul busts the myths surrounding lactic acidosis, anaerobic metabolism, tissue hypoxia and the role of lactate in sepsis.
Key take-away facts include:
- The production of lactate actually consumes hydrogen ions. Lactic acidosis is really lactic alkalosis.
- Lactate is produced physiologically and is a precursor for gluconeogenesis.
- During exercise, skeletal muscle exports lactate as the primary fuel for the heart and brain.
- At VO2max, intracellular oxygen stays the same. Anaerobic metabolism in cells only occur as a pre-terminal event. The exception is in complete arterial occlusion.
- Adrenaline promotes lactate production
- Lactate infusion has been shown to increase cardiac output in septic and cardiogenic shock
- Lactate is a survival advantage!
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.
Learning from excellence in critical care
Adrian Plunkett describes how to learn from excellence in critical care. Learning from excellence is an initiative which began at Birmingham Children’s Hospital.
Firstly, Adrian shares an anecdote regarding how the initiative begun. He sent a letter to the CEO of a hospital appreciating one of the doctors who treated him for cancer. The doctor unfortunately never received it. This caused Adrian to ask - is appreciation and gratitude undervalued?
Evidently, noticing excellence will lead to two things: learning new insights and increasing staff morale.
Adrian raises the question, why we do we not focus on the good things? We spend all our time improving safety and quality even though accidents and disasters are only a small percentage of what we do.
Moreover, Adrian claims that people inherently have negative biases. This is evident in healthcare, so how can we combat this?
The solution is to focus on excellent care. This led to the formation of a reporting system called Learning from Excellence (LfE), where people answer two questions: Who did something excellent? What did they do?
LfE is a formal system for reporting and providing positive feedback and appreciation to the healthcare workers. It is a beneficial and constructive way of learning from excellence.
Finally, Adrian explains, “Saying ‘thank you’ or ‘well done’ is the easiest quality improvement intervention of all.”
Learning from excellence in critical care by Adrian Plunkett
For more like this head to our podcast page. #CodaPodcast
The Broken Heart by Pete McCanny
Pete McCanny gives a talk on the cutting edge management of cardiogenic shock and challenges the conventional approach to mechanical support.
ICU year in review - Paul Young and Flavia Machado
Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.
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).
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
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?
Biomarkers in Critical Care: Mervyn Singer
Mervyn Singer discusses the use of biomarkers in critical care.
Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED.
These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth!
Prognostication can happen as early as the Emergency Department.
Studies from the States have found high levels of inflammatory cytokines can predict death, separately from clinical presentation. Therefore, we can predict when critically ill patients are destined to die. So, does this mean that we are just prolonging the life of those destined to die in critical care? Perhaps.
Mervyn discusses this being the possible reason for many failed ICU studies. Concurrently, the only progress in critical care in the past 20 years may be due only to less iatrogenic harm.
Furthermore, he explains his experiments with rats demonstrating the use of cardiovascular parameters, cytokines, troponins and even cholesterol being accurate prognostic biomarkers.
Then, Mervyn goes on to identify the use of steroids in sepsis. He talks about research that demonstrates a benefit to steroid use, but only in those patients predicted to die using the aforementioned biomarkers. This could be a key to selecting an appropriate patient group to allocate a specific treatment too.
Furthermore, we examine treating sepsis with beta blockers. Giving beta blockers to everyone has no effect at best and a harmful effect at worst. However, giving beta-blockers to those who were predicted to die conferred benefit!
In conclusion, we can predict outcome early in disease. This may allow better selection of patients for certain treatments! We thus need to adopt a completely different strategy for such patients predetermined to die. This also applies to trial design, especially where survival is the endpoint.
For more like this, head to our podcast page. #CodaPodcast
The Role of Love in Critical Care Leadership: Liz Crowe
The Role of Love in Critical Care Leadership by Liz Crowe.
There are times when this job can leave you heartbroken and love gets you through.
Bernard - Refractory Cardiac Arrest
Professor Stephen Bernard is an Intensive Care Physician at The Alfred Hospital and Medical Advisor to Ambulance Victoria. His research interests include the use of therapeutic hypothermia for the treatment of neurological injury after resuscitation from out-of hospital cardiac arrest. Here he provides a presentation on recent advances in the management of refractory cardiac arrest in the out of hospital setting.
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
The Use of Inhaled Nitric Oxide in Critical Care: Per P. Bredmose
Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient.
iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient.
Furthermore, it can be useful in both pre-hospital and in hospital care.
What is nitric oxide?
It is an endothelial derived potent short acting vasodilator mainly found in the pulmonary system. It also exists in other areas of the body. When nitric oxide is delivered via the inhaled route it has local effects only, with no systemic effects.
Most people will be familiar with the use of iNO in persistent pulmonary hypertension of the newborn.
However, there are other uses which are more “off label”. For instance, take the case of severe ARDS lungs in pre-hospital settings. These patients present challenges in retrieval for several reasons, including the retrieval ventilation systems being inferior when compared to hospital systems.
Of course, you could turn straight to ECMO. However, setting up ECMO takes time and is complex. It requires a large amount of equipment, skilled operators, and room. Nitric oxide can act as a bridge.
Per stresses, iNO is a tool to get the patient to the right place.
Nitric oxide is simple to use. It is an extra gas that goes into the ventilatory circuit. It is accessible, can be used in any vehicle, is easy to transport, and fast to grab and use. Much faster than a big ECMO set up or retrieval.
A lot of places have stopped using iNO and it has gained something of a bad reputation. The main reason for deleterious effects appears to be kidney injury. Per posits that this may be due to an increased length of time using the drug. Therefore, he advises caution.
Per concludes by explaining other conditions where iNO may be used as an adjunct to standard therapy. These situations include pulmonary hypertension, non-thrombotic pulmonary vasoconstriction, and pulmonary emboli.
Join Per Bredmose as he discusses all things inhaled nitric oxide.
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
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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:
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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
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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.
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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
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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.
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There is no such thing as mild, moderate and severe TBI - by Andrew Udy
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TBI Debate - Mild, moderate and severe categories work
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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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
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How to manage conflict in Critical Care: Ronan O’Leary
- 1. the neurosurgeons aren’t idiots ronan o’leary cambridge, uk @nccucambridge @ronanoleary
- 2. honestly…
- 4. will we ever work out which patients benefit from decompressive crainectomy?
- 7. fear is the path to the dark side fear leads to anger anger leads to hate hate leads to suffering
- 8. fear is the path to conflict fear leads to guilt guilt leads to anger anger leads to bias bias leads to information information leads to preconception …finances
- 9. Hospital Interprofessional conflict with a referring speciality Bradford Royal Infirmary Yes University Hospitals Birmingham Yes* Leeds General Infirmary Yes* The Alfred, Melbourne Yes* Cambridge University Hospitals Yes* *neurosurgeons present
- 10. Neurosurgeons present Neurosurgeons absent Total I was involved in conflict 4 6 10 I was not involved in conflict 0 0 0 Total 5 5 10
- 25. admission criteria stroke neutropaenic sepsis cancer over 80 obesity
- 26. it is much more important know about our patients’ diseases than to know about video laryngoscopes with apologies to osler