Pincer 12th sept2014 1
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This document summarizes hot topics in intensive care medicine that were presented by Steve Mathieu. It includes summaries of recent studies on ARDS treatments like HFOV, prone positioning, and statins. Guidelines on standards of care, tracheostomy procedures, blood transfusion, and AF management are reviewed. Recent studies on early versus late tracheostomy timing (TracMan) and HFOV versus conventional ventilation (OSCAR, OSCILLATE) in ARDS are summarized. The NAP4 study on airway complications in ICUs and operating rooms is also highlighted.
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Pincer 12th sept2014 1
- 1. Hot Topics in ICM Steve Mathieu Consultant in Intensive Care Medicine Queen Alexandra Hospital, Portsmouth 12th September 2014 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 2. Hot Topics/QuesCon spoDng • Syllabus • Examiners report • Review arCcles & key papers – JICS • Guidelines • Review FICM & ICS websites • CriCcal Eye • Other resources Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 4. Examiners Report April/May 2014 hRp://www.ficm.ac.uk/sites/default/files/document-‐files/EXM-‐FFICM-‐Summary-‐ChairmanReport-‐April2014_0.pdf
- 5. FFICM March 2013 April 2014
- 6. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 7. Original Ar4cles Reviews Case reports CAT reviews Others July 2014 Echo in PE Quality (pressure ulcers) DKA Acute mesenteric ischaemia Epidural abscess JW GI haemorrhage Mixed OD Acromegaly StaCn & VAP SEPSISPAM ProtecCve venClaCon in abdominal surgery Heart rate control in sepCc shock Delirium April 2014 Tracheostomy VAP Improving Cmeliness of Cme-‐criCcal transfers HIT HepaCCs B & C SedaCon Electrical muscle sCmulaCon in ICU (CIPN) HD for dabigatran associated coagulopathy Wernickes PaCent with tetanus TBI Hope ICU (delirium) CSL or HES TTM Prone venClaCon Capnography Jan 2014 COMET-‐UK (CO monitoring) Tracheostomy Right heart failure StabilisaCon and transport of criCcally ill child ECG and trauma Rhabdomyolysis PancreaCCs MDMA toxicity Hyperthyroidism Pulmonary haemorrhage and AKI TracMan AKI Organ donaCon Surveillance for VAP PE supplement October 2013 Echo NAVA venClaCon Pain Brainstem tesCng Plasma exchange in HUS Intralipid in felodipine toxicity Tracheostomy Transfusion strategies for upper GI bleed Prone TXA Survey on rehab aeer criCcal illness Echo in UK Blood transfusion in ICU BIS monitoring Faecal inconCnence in ICU July 2013 Noise level in ICU (delirium) Serious Hazards of Transfusion (SHOT) Medical support for heart failure PCT NO OTC deficiency Hyperkalaemia in HIV paCent with ‘PCP’ ICP monitoring SedaCon Gentamycin & vancomycin Ancillary tests in diagnosis of brainstem tesCng LCP
- 8. Guidelines Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 9. Standards -‐ quality • Staffing – Consultant presence • 24/7 & within 30 minutes – Consultant: paCent 1:8 – 1:15; ICU resident/ paCent 1:8 – Designated CD – Ward rounds x2 daily – Training / FICM / Board Tutors – Nursing 1:1 (level 3); 1:2 (level 2) – MDT e.g. physio, pharmacy, dieCcians • Opera4onal – Large ICUs divided into pods of 8-‐15 paCents – Admit within 4 hrs of decision to admit – Avoid non-‐clinical transfers – Transfer to ward – clear and formalised – Out of hours transfers – Readmission within 48 hours bad – Assessment of rehab for each paCent • Equipment – Training • Data Collec4on – ICNARC – Risk register Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 10. NCEPOD 2014: Tracheostomy • DocumentaCon & consent – IndicaCons, type, inner tube, reasons for failed extubaCon/why no trial of extubaCon • Different types of tubes • Rapidly available difficult airway trolley • Training programmes in blocked/displaced tubes • Capnography • Discharge of paCents with tracheostomy • MDT – physio & SALT Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 11. Tracheostomy standards ICS • IndicaCons for tracheostomy • CauCons and contraindicaCons • Consent • Equipment • Ultrasound • Anaesthesia • Staffing • Types of tracheostomy tubes • Inner cannulae • ComplicaCon – Early – Late – Airway emergencies
- 12. Guidelines • Blood transfusion – ABLE MulCcentre UK RBC transfusion (7d vs. 15-‐25d) – Transfusion triggers – TRICC & Villaneuva – Guidelines on the management of anemia and RBC transfusion in adult criCcally ill paCents h"p://www.bcshguidelines.com/documents/BCSH_Cri;cal_Care_Guidelines_Final_Version_22_10_12.pdf – Serious Hazards of Transfusion (SHOT) – JICS July 2013 • CalculaCon of Cerebral Perfusion Pressure • AF management – NICE & JICS • Clinical Guidelines on management of pain, agitaCon and delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 13. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • Transfusion Triggers • Blood conservaCon • Pre-‐transfusion clinical assessment • Rate of transfusion/fluid balance • InvesCgaCon adverse events • Storage duraCon
- 14. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 15. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth CCM 2013
- 16. Some guidelines Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 17. ConsultaCons Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 18. CriCcal Eye No 6: Core standards Examiners report No 5: FICM ConsultaCons: IV fluids (NICE – IV therapy in adults in hospital Dec 2013) Head injury & specialist centres Quality – quality indicators? No 4: 1st Examiners report – March 2013
- 19. The key papers in CriCcal Care Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 20. NAP 4 -‐ 2011 • All NHS hospitals for 1 year ’08-‐’09 • 184 reports " 133 anaesthesia " 36 ICU " 15 ED • Inclusion criteria " death, brain damage " emergency surgical airway " unanCcipated ICU admission " ProlongaCon ICU stay Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 21. Summary of NAP 4 " 25% of major airway events in a hospital occur in ICU or the ED " 46% of ICU events and 53% of ED events occurred out of hours " 50% of ICU events were due to tracheostomy related events " 50% events in ICU and 27% events in ED resulted in death " 61% events in ICU resulted in death or severe neurological harm Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 22. RecommendaCons " Capnography " Airway equipment " Back up planning " Staffing " PaCent transfers " EducaCon/training " Tracheostomy tube design " Team working Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 23. TracMan • 909 intubated paCents • Respiratory failure – < 4 days – Predicted to need MV for further 7 days • Tracheostomy Cming • Early (≤ 4 days) vs late (aeer 10 days) • No difference in – 30/7Mortality; ICU LOS; ComplicaCons • Only 45% late group received Academic Department of Critical Care trache Queen Alexandra Hospital Portsmouth
- 24. OSCAR • 795 paCents with moderate -‐ severe ARDS (<26.7kPa / 200mmHg) • CMV vs. HFOV (MV <7 days) • No difference in – 30/7 mortality (41%) – DuraCon anCmicrobial agents (2/3 chest sepsis) – VasoacCve support duraCon – ICU LOS – Hospital LOS Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 25. OSCILLATE • 548 paCents with moderate -‐ severe ARDS • HFOV vs low Vt/High PEEP CV (MV < 3d) • Trial stopped early as harm with HFOV • HFOV – Hospital mortality 47% vs 35% – More sedaCon – More NMBA’s – More vasopressors Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 26. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth OSCAR OSCILLATE 29 ICU’s UK 39 ICU’s 5 countries 795 paCents 548 paCents (planned 1200) PaO2:FiO2 < 200mmHg Bilateral pulmonary infiltrates MV for LESS than 7 consecuCve days at the point of randomisaCon PaO2:FiO2 < 200mmHg FiO2 > 0.5 Bilateral pulmonary infiltrates MV for LESS than 3 consecuCve days at the point of randomisaCon Encouraged to use PC 6-‐8mls/kg and use ARDS protocol for FiO2 & PEEP R 100 venClator PEEP 11 CV – PC 6mls/kg, 3100 B venClator Recruitment maneuvers before HFOV Protocol specified high PEEP for CV (PEEP 13) 30d mortality 42% vs. 41% (HFOV vs. CV) 30d mortality 40% vs. 29% Hospital mortality 47% vs. 35% (HFOV vs. CV) More NMBA’s More midazolam, vasoacCve drugs, NMBA’s in HFOV Lower PEEP strategy ? recruitment maneuvers of lung before HFOV injurious Mortality 41% in control group Mortality 35% in control group
- 27. PROSEVA • 466 paCents with severe ARDS • Prone posiCon vs supine posiCon • Prone posiCon was associated with – Improved mortality • 28 day: 16% vs 33% • 90 day: 24% vs 41% – Less cardiac arrests – No difference in complicaCons Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 28. PROSEVA Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 29. ARDS -‐ lots of trials " HFOV " Nitric Oxide " Surfactant " Perflourocarbon " " Late steroids (LaSRS)" " Prostaglandin E1 " " Lysophylline (LARMA)" " Ketoconazole (KARMA) " Streptokinase " StaCns (HARP 2, SAILS) " " Neutrophil elastase inhibitor " " ImmunonutriCon (Eden-‐ Omega)" " rhAPC " " Albuterol/salmeterol (BALTI I & II, ALTA) " " Lower Vt ! " ? Furosemide (FACTT) ! " Cisatricurium " Prone ‘back’ in Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 30. BALTI -‐ 2012 • 162 paCents; 46 UK ICU’s • ARDS & MV -‐ salbutamol 15mcg/kg/hr or placebo -‐ Treatment for up to 7 d • Mortality greater in those given salbutamol 34% vs 23% at 28d Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 31. StaCns in ARDS • MulCcentre, RCT • RosuvastaCn vs. placebo in ARDS • StaCn may modulate inflammatory response • 745 paCents (trial stopped early because of fuClity) • Primary outcome: • 60d mortality: 28.5% vs. 24.9% (staCn vs. placebo) • VenClator free days: 15.1 vs. 15.1 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 32. StaCn & VAP • 300 paCents with suspected VAP (CPIS ≥ 5) • SimvastaCn 60mg vs placebo • No difference in – 28d survival – ICU or hospital mortality – DuraCon MV – Delta SOFA • Increased mortality in staCn naieve Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 33. Magnesium in asthma • 1200 paCents 2008-‐2012 • Neb vs. IV Mg vs. placebo • No role for neb Mg • Limited role at best for IV Mg • Not life threatening asthma Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-‐ blind, randomised controlled trial Goodacre et al Lancet 2013 Vol 1 (4) 293-‐300 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 34. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • Meta-‐analysis • 16 trials inc PEITHO, MAPPETT, MOPETT, TOPCOT • Thrombolysis + anCcoagulaCon vs. anCcoagulaCon alone • All cause mortality less in thrombolysis group but major bleeding & ICH higher
- 35. TTM • 950 unconscious adults; 36 ICU’s • 33°C (n=473) with 36°C (n=466) • No difference in – All cause mortality 33°C (50%) with 36°C (48%) – poor neurological func4on at 180 days 33°C (54%) with 36°C (52%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 36. Pre-‐hospital hypothermia • Prehospital cooling vs. standard care • 2L of cold normal saline once ROSC • 1,359 OOHCA paCents • Cooling effecCve (reduced temp) • No difference – Survival to hospital discharge • VF 63% vs 64% • nonVF 19% vs 16% – Good neurological recovery • VF 57% vs 62% • nonVF 14% vs 13% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 37. IABP – SHOCK II • 600 paCents with cardiogenic shock secondary to AMI • IABP vs no IABP • All received early revascularisaCon and best medical therapy • No difference – 30/7 mortality (40%) – ICU LOS, catecholamine, bleeding • Lancet 2013 Sept – 12/12 results = no difference in mortality or reinfarcCon rate Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 38. VSE in cardiac arrest • 268 paCents in hospital cardiac arrest • Vasopressin(20IU/CPR cycle) + epinephrine (1mg/CPR cycle) + methylprednisilone (40mg) vs placebo + epinephrine (1mg/CPR cycle) • VSE group – ROSC at 20 mins higher 84% vs 66% – Improved survival to hospital discharge with CPC 1 or 2 – Improved haemodynamics & cvSpO2 – Less organ dysfuncCon Aca•d eamndic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 39. SEPSIS
- 40. Ferrer: Empiric anCbioCcs in sepsis • RetrospecCve observaConal cohort study • 165 ICUs – Europe, US & S America • Jan 2005-‐ Feb 2010 • 18,000 paCents with sepCc shock • Delay in anCbioCcs administraCon over first 6 hours aeer idenCficaCon of SS or sepCc shock -‐> increased mortality • < 1 hr 24.6%; 1-‐2h 25.9% > 6h 33% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 41. SEPSISPAM • RCT, mulCcentre, 29 French ICUs • March 2010 – Dec 2011 • SepCc shock • Target MAP 80-‐85 vs. 65-‐70 • No difference in – 28 day mortality (high MAP 36.6% vs. 34%) • New AF 6.7% in higher MAP group vs. 2.8% P=0.02 • In chronic hypertension group, worsening creaCnine and need for RRT was lower in higher MAP group Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 42. OPTIMISE • RCT, mulCcentre, 17 UK ICUs • 734 paCents • > 50y undergoing GI surgery with one or more ‘high risk’ risk factors • Algorithm-‐directed care dictaCng colloid and dopexamine administraCon using vs. clinician directed care without use of CO monitoring • Primary outcome: composite of 30d mortality and mod/major complicaCons – IntervenCon: 36.6% – Control arm: 43.4% • No SS difference in secondary outcomes – POMS, infecCous complicaCons, criCcal care free days at 30d, mortality at 30d and 180d, hospital LOS Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 43. PROWESS SHOCK • Randomised, controlled, mulCcentre, parallel group study • 1,697 paCents with sepCc shock • No difference in – 28 day mortality (APC 26.4% vs 24.2%) – 90 day mortality (34.1% vs 32.7%) • No subgroup effect seen in protein C deficient group • Serious bleeding n = 10 APC vs 8 placebo Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 44. VANISH Academic Department of Critical Care Queen Alexandra Hospital Portsmouth Vasopressin & corCcosteroids in SepCc Shock. A Pilot Study – Gordon A, 2014 HydrocorCsone -‐ vasopressin sparing -‐ reduced duraCon vasopressin -‐ reduced dose vasopressin -‐ no effect on vasopressin levels
- 45. B blockers in sepCc shock • Open label, single unit • SepCc shock + HR ≥ 95 + NADR • 77 paCents – esmolol infusion (HR 80-‐94) vs 77 paCents standard treatment • Esmolol group – 28d Mortality 50% vs 81% in placebo – Improved SV index, LVSWI, lactate – Less NADR requirement – Less fluid requirement Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 46. CirculaCon Sepsis & EGDT ProMISe – UK – soon… ARISE – Australia – ESICM 2014 ProCESS – US -‐ complete Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 47. ProCESS • RCT 31 ICUs in US • 03/2008 – 05/2013 • 1351 paCents with sepCc shock • 3 groups – EGDT – Protocol based standard therapy – Usual care – No difference in 60 d mortality between groups Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 48. IVOIRE Study • Randomised, open study • 18 ICU’s in France, Belgium and Netherlands 2005-‐2010 • 140 pts with sepCc shock & AKI • HVHF 70mls/kg/hr v 35mls/kg/hr • Slow recruitment • No difference in mortality = 40% 28/7 • HVHF not recommended Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 49. Fluids • Don’t give too much • Don’t give too liRle • Make sure you give the right amount • Starches bad…very bad AssociaCon of HES administraCon with mortality and AKI in criCcally ill paCents requiring volume resuscitaCon. Meta-‐ analysis. JAMA 2013 vol 309 (7) • Albumin back in? SAFE subgroup analysis 1200 pts with severe sepsis -‐ 28/7 mortality lower in albumin group (30% vs. 35% OR 0.87) Finfer S et al 2011 Intensive Care Med 37:86–96 Delayney metaanalysis. Role of albumin as a resuscita;on fluid for pa;ents with sepsis. 17 studies, 1977 pa;ents. Crit Care Med 2011 Albios Study – GaXnoni (video ion ESICM website) “lets talk about fluid responsiveness” Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 50. ALBIOS • RCT, 100 ICUs in Italy • Aug 2008 – Feb 2012 • 1818 paCents with severe sepsis • 300mls 20% HAS daily to maintain serum albumin at 30g/dl + CSL vs. CSL • Primary outcome: mortality at 28d – HAS + CSL: 31.8% – CSL: 32% • Secondary outcomes: 90 d mortality – No difference Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 51. 6S Study • 804 ICU pts with severe sepsis • Compared fluid resuscitaCon – 130/0.4 hydroxyethyl starch (tetraspan) vs Ringer's acetate • HES associated with – Increased 90 day mortality 51% vs 43% – Increased RRT requirement 22% vs 16% – Trend for increased bleeding 10% vs 6% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 52. CHEST Study • 7000 ICU pts • Fluid resuscitaCon with 6% HES 130/0.4 (Voluven) or 0.9% saline • No differences in – Mortality (HES 18% vs 17%) – LOS – ICU / Hospital • HES associated with increased – RRT (7% vs 5.8%; RR 1.21) – Pruritus / Rash / HepaCc failure -‐ Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 53. CRISTAL Study • 2857 sequenCal ICU paCents 2003-‐2012 57 ICU’s • Colloids vs CSL for all fluid intervenCons other than maintenance • Colloids – Reduced mortality at 28d & 90d (25% vs 27% & 30% vs 34%) – More days alive without MV – More days alive without vasopressors – Less RRT Academic Department of Critical Care -‐ Queen Alexandra Hospital Portsmouth
- 54. Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 55. ESICM statement on colloids 1. Recommend not to use HES with mw ≥ 200kDa in paCents with severe sepsis or risk of AKI 2. Suggest avoid 6% HES or gelaCn in these groups 3. Recommend not to use colloids in paCents with head injury and not to administer gelaCns and HES in orhan donors 4. Suggest avoid hyperoncoCc soluCons for fluid resuscitaCon Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 57. TRAUMA
- 58. TXA " CRASH -‐ 2 Lancet 2010 • tranexamic acid in reducing transfusion requirements and death from significant haemorrhage following injury • 20,000 paCents • Risk of haemorrhage reduced by 0.8% • No reducCon in transfusion usage • Only 50% received blood and average only 3 (? ‘significant haemorrhage’) " CRASH -‐ 2 subanalysis Lancet 2011 • Mortality directly related to haemorrhage • Tranexamic acid only effecCve if within first 3 hours. Beyond this Cme mortality increases Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 59. TXA " CRASH – 2 Does TXA reduce the risk of intracranial bleeding in pa4ents with TBI? BMJ 2011 • 250 of the 20,000 paCents eligible. • Brain haemorrhage growth 5mm vs. 8mm (TXA vs. placebo) • Not SS • No menCon of extent of extracranial injuries in either group making mortality comparisons difficult • Not well matched as there were more pts with SAH (61% vs 43%) • No increase is focal cerebral ischaemia • Conclusion “it is probable that benefits of tranexamic acid outweigh risks’ Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 60. Trauma Haemorrhage 1. CoagulaCon monitoring and measures to support coagulaCon should be implemented early 2. Damage control surgery 3. Physiological targets, suggested use & dosing of fluids, blood products and TXA 4. PaCents on anCplatelet agents and/or oral anCcoagulants require special aRenCon 5. Mutlidisciplinary approach & evidence based protocols adapted to local circumstances need to be developed and implemented Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 61. Neuro-‐ICU ICP Monitoring • MulCcentre RCT of 324 paCents Bolivia and Ecuador • Intraparenchymal ICP monitoring vs. clinical & imaging • No difference in mortality or neuropsycholoigcal status at 6/12 A Trial of Intracranial-‐Pressure Monitoring in TraumaCc Brain Injury Randall M. Chesnut et al N Engl J Med 2012; 367:2471-‐2481 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 62. Neuro
- 63. CATIS • 4,071 paCents • Within 48 hrs ischaemic stroke • nonthrombolysed and ↑BP • Hypertension therapy vs no BP Rx • BP control effecCve • No difference – death and major disability • 14 days / hospital discharge • 3 months Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 64. INTERACT 2 • 2,839 pts with early spontaneous intracerebral haemorrhage & ↑SBP • Compared SBP <140 mmHg vs <180 • Aggressive BP control associated with – Trend for less adverse events (p=0.06) – Lower modified Rankin scores • No difference in mortality Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 65. Magnesium for aneurysmal SAH (MASH-‐2): a randomised placebo-‐controlled trial Mees S et al. 2012 The Lancet. Vol 380 9834:44-‐49 • 8 ICU’s in Europe and S America • 1204 paCents • The quesCon: does Mg reduce poor outcome by reducing vasospasm and delayed cerebral ischaemia (DCI) • Magnesium 64mmol/day for 20/7 or placebo • Primary outcome of poor outcomes as defined by score 4-‐5 on modified Rankin Scale at 3/12, or death • NO DIFFERENCE Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 66. Delirium HOPE ICU • 142 paCents with delirium • CAM-‐ICU assessment • Double blinded • Haloperidol vs. placebo • No change in duraCon of delirium in criCcally ill paCents • Haloperidol should be reserved for short term management on acute agitaCon Effect of intravenous haloperidol on the dura4on of delirium and coma in cri4cally ill pa4ents (Hope-‐ICU): a randomised, double-‐blind, placebo-‐controlled trial Valeirie Page. The Lancet Respiratory Medicine, Volume 1, Issue 7, Pages 515 -‐ 523, September 2013 Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 67. TreaCng delerium 101 MV pa4ents RCT haloperidol vs. ziprasidone vs placebo 21/7 study period No difference in any of the groups!
- 68. The beginning; Kress NEJM 2000 ReducCon in LOS Girard Lancet 2008 Decreased ICU stay, Cme on venClator and mortality Strom Lancet 2010 ReducCon in LOS and venClator days No sedaCon group -‐ boluses of morphine, well established in insCtuCon, more agitated delerium in no sedaCon group Ryker JAMA 2009 ReducCon in venClator days and delirium Jacob JAMA 2012 PRODEX/MIDEX No beRer than midaz or propofol at maintaining light to mod sedaCon and more adverse effects. Increased paCent interacCons. Less vent days than midazolam Mehta 2013 For MV paCents managed with protocolised sedaCon, the additon of daily sedaCon interrupCon did not reduce duraCon MV or ICU LOS
- 69. The beginning; Kress NEJM 2000 ReducCon in LOS Girard Lancet 2008 Decreased ICU stay, Cme on venClator and mortality Strom Lancet 2010 ReducCon in LOS and venClator days No sedaCon group -‐ boluses of morphine, well established in insCtuCon, more agitated delerium in no sedaCon group Ryker JAMA 2009 ReducCon in venClator days and delirium Jacob JAMA 2012 PRODEX/MIDEX No beRer than midaz or propofol at maintaining light to mod sedaCon and more adverse effects. Increased paCent interacCons. Less vent days than midazolam Mehta 2013 For MV paCents managed with protocolised sedaCon, the additon of daily sedaCon interrupCon did not reduce duraCon MV or ICU LOS
- 70. Don’t forget the simple things…. • Small RCT 136 paCents • Used NEECHAM score • Delirium (20%) similar but less mild confusion with ear plugs and good night sleep <50% vs. 25%
- 71. Guidelines for managing delirium Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 72. GastrointesCnal
- 73. Acute UGI Bleed • Randomised, parallel group study • 921 pts with severe upper GI bleeding • Compared restricCve (Hb <7g/dL) vs liberal transfusion strategy (Hb<9g/dL) • RestricCve strategy associated with – Reduced number of pts receiving transfusion (15% vs 51%) – Increased probability survival (HR 0.55) – Less rebleeding (10% vs 16%) – Less adverse events (40% vs 48%) Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 74. GastrointensCnal
- 75. The SuDDICU study SDD 12 meta-‐analyses of 28 RCT’s. 10 show reduced pneumonia rate; 6 show morality benefit • Why have clinicians avoided implemenCng it in UK? • What are the barriers? • What further evidence is required before full scale clinical implementaCon Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 76. SystemaCc review: CCM 2010 • Those paCents receiving enteral nutriCon, stress ulcer prophylaxis may not be required and may actually increase VAP
- 77. H2R antagonists vs PPI • Cohort Study of 35,000 pts • MV > 24 hours and either H2R antagonist or PPI • H2R antagonist group had – Less GI haemorrhage 2.1 vs 5.9% – Pneumonia 27% vs 39% – C.Diff 2.2% vs 3.8% Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 78. Hepatology • ALD " Alcohol related illness costs NHS £1.7 billion/year " SystemaCc review of 21 arCcles " Overall ICU mortality 40-‐50% " Mackle study only one to provide data on GI haemorrhage -‐ mortality 48%, 62%, 67%,68% for unit, hospital, 6/12 and one yr -‐ if get out of hospital most will survive " Organ support -‐ 3 papers (venClaCon, vasoacCve drugs, RRT) " Mackle -‐ -‐ if MV and vasoacCve drugs hospital mortality 86% -‐ If MV, vasoacCve drugs and RRT > 90% -‐ If just MV 31% " Saliba RRT 90% " Rye 100% mortality if require RRT Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 80. FuncConal disability 5 years aeer ARDS " 109 survivors from ’98 -‐ ’01 " Interview, PFT’s, 6 min walk test, resCng & exercise oximetry, chest imaging, QOL survey " PFT’s normalish " BUT 6 min walk test 76% predicted, physical/ psychological problems Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 81. Some guidelines Academic Department of Critical Care Queen Alexandra Hospital Portsmouth
- 82. Suggested resources Academic Department of Critical Care Queen Alexandra Hospital Portsmouth • JICS • Sign up to criCcalcarereviews.com • Podcasts • LITFL • FFICM & ICS
- 83. Best of Luck! Academic Department of Critical Care Queen Alexandra Hospital Portsmouth www.wessexics.com @WessexICS @WICSBoRomLine @stevemathieu75