When to Initiate RRT in Patients with AKI - Does Timing Matter?Apollo Hospitals
Acute kidney injury is a serious illness which occurs commonly in the renal units and also in the ICU setting. It is an independent risk factor of increased mortality and morbidity, particularly when RRT is needed. The wide variation in utilization of RRT contributes to a lack of consensus among clinicians regarding the parameters which should guide the decision to initiate RRT. This problem is confounded by a paucity of high quality evidence in the current literature. This review examines the role of usual biochemical parameters as well as conventional clinical indications for commencing RRT. It also discusses the potential role of biomarkers as predictors for the need of RRT in AKI. Initiating dialysis in AKI should be based on dynamic clinical criteria and not only on specific biochemical values.
When to Initiate RRT in Patients with AKI - Does Timing Matter?Apollo Hospitals
Acute kidney injury is a serious illness which occurs commonly in the renal units and also in the ICU setting. It is an independent risk factor of increased mortality and morbidity, particularly when RRT is needed. The wide variation in utilization of RRT contributes to a lack of consensus among clinicians regarding the parameters which should guide the decision to initiate RRT. This problem is confounded by a paucity of high quality evidence in the current literature. This review examines the role of usual biochemical parameters as well as conventional clinical indications for commencing RRT. It also discusses the potential role of biomarkers as predictors for the need of RRT in AKI. Initiating dialysis in AKI should be based on dynamic clinical criteria and not only on specific biochemical values.
When to Initiate RRT in Patients with AKI - Does Timing Matter?Apollo Hospitals
Acute kidney injury is a serious illness which occurs commonly in the renal units and also in the ICU setting. It is an independent risk factor of increased mortality and morbidity, particularly when RRT is needed. The wide variation in utilization of RRT contributes to a lack of consensus among clinicians regarding the parameters which should guide the decision to initiate RRT.
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
When to Initiate RRT in Patients with AKI - Does Timing Matter?Apollo Hospitals
Acute kidney injury is a serious illness which occurs commonly in the renal units and also in the ICU setting. It is an independent risk factor of increased mortality and morbidity, particularly when RRT is needed. The wide variation in utilization of RRT contributes to a lack of consensus among clinicians regarding the parameters which should guide the decision to initiate RRT.
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
The assessment, diagnosis and treatment of critically ill patients is extremely challenging. Patients often deteriorate whilst being
reviewed and their rapidly changing pathophysiology barrages healthcare professionals with new data. Furthermore, comprehensive assessments must be postponed until the patient has been stabilised. So, important data and interventions are often missed in the heat of the moment. In emergency situations, suboptimal management decisions may cause signifi cant morbidity and mortality. Fortunately, standardisation and careful design of documentation (i.e. proformas and checklists) can enhance patient safety. So, I have developed a series of checklist proformas to guide the assessment of critically ill patients. These proformas also promote the systematic recording and presentation of information to facilitate the retrieval of the precise data required for the management for critically ill patients. The proformas have been modifi ed extensively over the last twenty years based on my personal experience and extensive consultation with colleagues in several world-renowned centres of excellence. The proformas were originally developed for use in the intensive therapy unit
or high dependency unit. However, they have been adapted for use by outreach teams reviewing patients admitted outside of critical care areas. The use of these tools can direct eff orts to provide appropriate organ support and provides a framework for diagnostic reasoning.
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Resuscitation from Severe Sepsis: do we need care bundles?
1. IFAD Antwerpen 2013
Azriel Perel
Professor and Chairman
Department of Anesthesiology and Intensive Care
Sheba Medical Center, Tel Aviv University
Israel
Resuscitation from Severe Sepsis:
do we need care bundles?
2. Disclosure
The speaker is a member of the
Medical Advisory Board of
Pulsion Medical Systems,
Munich, Germany
Consulted until recently to BMEYE, FlowSense, iMDsoft
3. “Because of the complexity of
hemodynamics in sepsis, the goals of
therapy are much more difficult to
define with certainty than in other forms
of shock.”
Practice parameters for hemodynamic support of sepsis
in adult patients. 2004 update.
Hollenberg S et al. Crit Care Med 2004; 32:1928-48
9. “In most patients with septic shock, CO will
be optimized at filling pressures (PAOP)
between 12-15 mmHg [26].
Increases above this range…increase the
risk for developing pulmonary edema.”
26. (III) Packman MJ, Rackow EC: Optimum left heart filling
pressure during fluid resuscitation of patients with
hypovolemic and septic shock. Crit Care Med 1983; 11:165-9
Level D recommendation
Practice parameters for hemodynamic support of sepsis
in adult patients. 2004 update.
Hollenberg S et al. Crit Care Med 2004; 32:1928-48
14. Targeting dynamic measures of fluid responsiveness
during resuscitation, including flow (CO) and possibly
volumetric indices and microcirculatory changes, may
have advantages
19. Crit Care Med 2006, 34:1025-1032
Initial ScvO2 72 ± 11%
Initial ScvO2 73 ± 13%
Initial ScvO2 74 ± 10%
Initial ScvO2 73 ± 11%
The mean ScvO2 of Rivers’ patients was 50%!!!
A normal/high SvO2 may be due to reduced O2
extraction and does not necessarily indicate
adequate tissue oxygenation
20. Severe Global Tissue Hypoxia and
Low O2 Extraction
Lactate > 4 mmol per liter and ScvO2 >70%
CCM 2007
21.
22. The extremely low ScvO2 values seen in Rivers’
patients on admission to the ED indicate that these
patients had very low cardiac outputs.
The most probable cause for their low CO was a
combination of pre-existing co-morbidities and
hypovolemia, which may have developed due to a late
arrival to the hospital (black, low socioeconomic status,
no insurance).
The very significant hypovolemic element of their
shock was successfully corrected by aggressive fluid
loading which was guided by a simple protocol that may
be unsuitable for many ICU septic patients.
23. Very recent literature from the US emphasizes the
effects of race and socio-economic conditions on
sepsis outcome.
The Rivers study was done in the Department of
Emergency Medicine which serves “metro Detroit’s
largely poor, largely minority population, having poor
health status and high chronic disease incidence”
Ann Emerg Med Dec. 2008
“Outcome of Americans without insurance who are
admitted to the ICU is worse, possibly because they
are sicker when they seek care.”
Danis M, et al. Crit Care Med 2006; 34:2043
Do the Rivers’ patients represent all septic patients?
24.
25. “Shocked” wouldn't be accurate, since we were accustomed to
our uninsured patients' receiving inadequate medical care.
“Saddened” wasn't right, either, only pecking at the edge of
our response. And “disheartened” just smacked of victimhood.
After hearing this story, we were neither shocked nor saddened
nor disheartened. We were simply appalled…..
We find it terribly and tragically inhumane that Mr. Davis and
tens of thousands of other citizens of this wealthy country will
die this year for lack of insurance.
26. Dr. Rivers's explanation of the higher death
rate for those on conventional care
compared with data from other countries, is
that his patients were sicker.
27.
28. Rawlins MR: De Testimonio.
Harveian oration 2008, Royal College of Physicians
29.
30. There are only 10 references supporting
the 6H bundle; they have not been
updated over the years
Total number of references in the SSCG
grew form 135 (2004), to 341 (2008),
and to 636 (2012)
31. A large number of observational studies
have shown significant mortality reduction
compared to the institutions’ historical
controls.
32. Crit Care Med 2010; 38:668–678
As administered and studied to date, only
antibiotics meet the stated criteria of proof for
bundle inclusion.
33. The reported improved survival following the
adoption of these (SSC) Guidelines….cannot
be viewed as justification of the initial
hemodynamic resuscitation protocol.
Physiologically and clinically this protocol
may be wrong for many septic patients.
34. Attainment of a CVP of >8 mmHg and
ScvO2 of >70% did not influence
survival in patients with septic shock*.
*Voluntarily submitted data on 15,022 patients
39. “Surely, we recognize the need to give up
some measure of autonomy…yield some
decision-making power…
The data certainly suggest that when we
surrender this autonomy and standardize
care, patients do better.”
M. Levy, SCCM 2009
38th SCCM Conference Perspectives
40. The 3 phases of the SSC
1. Introduction at several major international critical
care medicine conferences.
2. Creating evidence-based guidelines for the
management of severe sepsis and septic shock.
3. To operationalize the SSC guidelines into a set of
practical yet valid performance measure.
41. The sepsis bundle includes only
recommendations that can be converted into
data elements that can be precisely defined,
with clearly identified failure modes, and that
could be measured by retrospective chart
audit.
42. The bundle is well-established, proven in
scientific tests and based on randomized
controlled trials, what we call Level 1 evidence.
C.H. PhD, IHI Vice President
and patient safety expert
A bundle must be followed for every patient,
every single time. There should be no
controversy involved, no debate or discussion of
bundle elements.
Addition of other strategies not found in the
bundles is not recommended.
43.
44. The guidelines attempt to include nearly every aspect
of critical care potentially related to sepsis, perhaps
losing focus in the process.
The evidence behind some of the ‘bundles’ is not
strong, e.g., CVP.
These bundles are being turned into quality measures
on which providers will be benchmarked, even though
clinicians may validly disagree with some of the
recommendations.
45. While only 47% of surveyed intensivists
believed that CVP should guide
resuscitation, 86% used it because of
the Surviving Sepsis Campaign
Guidelines.
46. Bundled performance
measures are ready made for
use in pay-for-performance
initiatives, which can base
reimbursement on
compliance with all the
components. Are you compliant?
47. Complete compliance with all applicable
elements of the sepsis resuscitation
bundle was 21.6% in the USA and 18.4%
in Europe.
48. Even in these highly selected and committed
institutions compliance with both the
resuscitation and the management bundles
was only about 20%.
This suggests that compliance is either quite
difficult, or that clinicians disagree with some
aspects of the guidelines and specifically do
not reach compliance.
50. The performance indicators for bundle compliance now
call for measuring CVP and SCVO2, and re-measuring
lactate if the initial lactate was elevated.
The rationale for the indicators’ being measurement
and not target achievement is that the decision to give
more fluid or add inotropes to the resuscitation should
be based on the entire clinical picture.
Institutions that can bring more advanced technologies
to the bedside may do so and use those measurements
as part of the total clinical picture for decision making.
51. The performance indicators for bundle compliance now
call for measuring CVP and SCVO2, and re-measuring
lactate if the initial lactate was elevated.
The rationale for the indicators’ being measurement
and not target achievement is that the decision to give
more fluid or add inotropes to the resuscitation should
be based on the entire clinical picture.
Institutions that can bring more advanced technologies
to the bedside may do so and use those measurements
as part of the total clinical picture for decision making.
52. Thank you for your attention!
Conclusions:
Rivers et al have started one of the most
important process in modern critical care and
the SSC is saving lives as we speak.
And yet, the physiological variables that the SSC
recommends to direct the initial hemodynamic
resuscitation are not suitable for all septic
patients and may be harmful.
Attempts to protocolize care in critically ill
patients have to leave room for clinical judgment
that takes into account the whole clinical
picture.
53.
54. Sponsoring Organizations
American Association of Critical Care Nurses
American College of Chest Physicians
American College of Emergency Physicians
American Thoracic Society
Australian and New Zealand Intensive Care Society
European Society of Clinical Microbiology and Infectious
Diseases
European Society of Intensive Care Medicine
European Respiratory Society
International Sepsis Forum
Society of Critical Care Medicine
Surgical Infection Society
55.
56. In part, physician noncompliance
with evidence-based guidelines can
be explained by weaknesses in the
evidence base itself.
57. In recent years, the developers of practice guidelines
have started grouping evidence-based interventions into
“bundles,” on the theory that inducing physicians to
follow multiple recommendations written into a single
protocol has a measurable effect on patients’ outcomes.
Seeing in these bundles a potentially powerful vehicle
for promoting their products, pharmaceutical and
medical-device companies have begun to invest in
influencing the adoption of guidelines that serve their
own financial goals.
58. “For every patient, every single time”
“No controversy involved, no debate or discussion”
59. “Clearly, SvO2 is the gold standard for
defining global adequacy of
cardiovascular performance.”
Crit Care Med 2005; 33:1119-22
60. It is useful to measure SvO2 because if
cardiac output becomes inadequate, SvO2
will decrease.
A low SvO2 should prompt rapid
intervention to increase oxygen delivery to
the tissues.
66. “Medicine has become complex. Details
have become overwhelming for clinicians
to process at the bedside…
Surely, we recognize the need to give up
some measure of autonomy…yield some
decision-making power…
The data certainly suggest that when we
surrender this autonomy and standardize
care, patients do better.”
M. Levy, SCCM 2009
38th SCCM Conference Perspectives
67.
68. Study Year Country
Compliance
6H bundle
Compliance
24H bundle
Overall
compliance
Gao F et al 2005 UK 52% 30%
Ferrer R et al 2008 Spain <10%
Mikkelsen ME et al 2010 USA 43%
Castellanos-Ortega et al 2010 Spain 34% 40%
Flavia R et al 2010 Brazil 9%
Levy MM et al 2010 USA 22% 26%
Vesteinsdotir E et al 2011 Iceland 35% 45%
Shiramizo SCPL et al 2011 Brazil 14% 44%
Tromp M et al 2011
Netherla
nds
27% 25%
Phua J et al 2011 Asia 8% 4%
Rinaldi L et al 2012 Italy 50 % 52% 39%
Wang Z et al 2013 China 1% 9%
Reported compliance rates with SSC bundles
69. These recommendations highlight the fact that the
GRADE system, though transparent, is still subjective
- the recommendations depend greatly on the values
and preferences of the committee members.
Developers are allowed to make strong
recommendations when the quality of evidence is
weak, or weak recommendations when the quality of
evidence is strong
70. Among the limitations of the guideline is the fact that
it attempts to include nearly every aspect of critical
care potentially related to sepsis, perhaps losing
focus in the process.
The guidelines also emphasize ‘bundles’ of care for
sepsis resuscitation, although the evidence behind
some of the bundled recommendations is not strong,
e.g., CVP.
Already, these bundles are being turned into quality
71. CO = 12-15 L/min
SVR = 400-500
ITBVI = 1200 ml/m2 (800-1000)
EVLW = 19-23 ml/kg (~7)
BP 70/40 mmHg
HR 155 bpm
CVP 5 cmH2O
PaO2/FiO2 80 (PEEP 16)
Low !!!
High !!!
High !!!
High !!!
Would you give fluids to this patient?
A patient with head injury, severe ARDS and septic shock
Noradrenaline + aggressive diuresis!
X
Can this patient “afford” the price of a possible mistake?
72. Some consensus
statements are being
turned into
performance measures
and other tools to
critique the quality of
physician care.
Are you compliant?
73. More than 80% of trauma centers that treat
mostly minority uninsured patients have
higher death rates than do trauma centers
that treat mostly white and insured patients.