EuAsia 2017 Day 3: Trauma

Initial trauma care (J Duranteau)

STOP THE BLEEDING – requires multidisciplinary task force

Communication vital

A major trauma centre is a specialty hospital not a hospital of specialties.

Damage control surgery and resuscitation should be emphasised by the team

Minimise time between arrival and operation

Aim for systolic BP 80-90mmHg (if TBI MAP 80mmHg)

  • Duranteau – if no response after 1l fluids, start vasopressors

Correct coagulopathy

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References

A major trauma centre is a specialty hospital not a hospital of specialties.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

 

Ultrasound in trauma: what you need to know (A Wong)

 

Can trauma care be improved with simulation (HY So)

Simulation – strategy to mirror, anticipate or amplify the real situation

Learning process amongst professional is complicated

Debrief structure phase

  • Introduction
  • Reaction – emotion before cognition, go where the heat is
  • Debrief with good judgement

Simulation advantages

  • deliberate practice with feedback
  • uncommon events
  • reproducibility
  • ability to range the difficulty levels
  • absence of risk to patients

Hurdles

  • learners do not ‘buy in’
  • fidelity problematic
  • threatened – psychological safety crucial
  • confidentiality

Training the trainer is important

I hear and I forget. I see and I remember. I do and I understand. Confucius

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EuAsia Day 3: Metabolic issues

Hyponatraemia: European guidelines (E Hoste)

Proportion of ICU pts with hypoNa (<135) – 14 to 27%

Acute hypoNa – < 48hrs

Symptoms variable

Guideline recommends treating for severe symptomatic hypoNa with 150mls of 3%NaCl over 20 minutes, aim for Na increase of 5mmol/L

Aim to correct severe hypoNa by 10mmol/L in D1 (8mmol/L D2) until pt asymptomatic or Na >130

IF corrected too quickly – add in 5% dextrose and/or consider desmopressin 2mcg (per 8hr)

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References:

Clinical practice guideline on diagnosis and treatment of hyponatraemia

 

Nutrition in ICU (Ostermann)

Malnutrition is associated with poor outcome

Critically ill patients lose 10-20% of body protein within a week

Resting energy expenditure – Estimation/Harris and Benedikt/Indirect calorimetry

TICACOS trial – enteral feeding with energy target determined by estimation (control) vs indirect calorimetry

  • Improved survival in pts where targets were met
  • Better outcomes in control group (estimation 25kcal/kg/day)

CALORIES Trial (TPN)

  • No significant difference in groups

ESICM Guidelines (2017)

  • Early enteral nutrition as a default
  • Delay enteral nutrition in specific cases e.g. uncontrolled shock, bowel ischaemia, life threatening hypoxaemia/hypercapnia/acidosis
  • Not to delay EN in prone position

ASPEN (2016)

  • PN initiated ASAP in high risk groups if EN not feasible
  • PN can be considered in low risk pts after 7-10 days if unable to meet >60% energy goal
  • Immune0modulating enteral formulation should be considered in pts with severe trauma or TBI or post-operatively

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References:

The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

 

Liver failure: how to support (Gruber)

Liver dysfunction common but acute liver failure is rarer

Liver dysfunction post immunotherapy (as part of cancer treatment) is not uncommon

  • Supportive care
  • Steroids 1-2mg/kg/day

Commonest cause on ICU – sepsis

Cirrhotic pts have vascular hypo-reactivity due to increase NO levels

Relative adrenal insufficiency is common

Septic liver pts

  • Supportive
  • Prophylaxis – encephalopathy, GI bleeds, infection
  • High risk of fungal infection

Acute variceal haemorrhage

  • oesophageal varices common
  • Peak re-bleed day 5
  • Endoscopic and interventional radiology interventions
  • Reduction of portal pressure – octreotide, somastatin etc

AKI common but majority is NOT hepato-renal syndrome (HRS)

  • 2 types of HRS: type 1 rapid and poorer outcomes
  • Specifically for HRS: albumin/terlipressin
  • RRT as a bridge (consider citrate)

Liver support systems

  • MARS, RELIEF, PROMETHIUS
  • Failed to show mortality benefits

References:

Acute-on-chronic liver failure definitions

Acute esophageal variceal bleeding: Current strategies and new perspectives

EuAsia 2017 Day 2: Not only bacteria

Pre-emptive strategies in non bacterial infection (J De Waele @CriticCareDoc)

Invasive candidiasis has a high mortality (>50%) and expensive (>USD 40K), yet difficult to diagnosis

Terminology important – prophylaxis, pre-emptive, empirical vs directed therapy

Cochrane review available

Risk factors – antibiotic exposure, CVC, TPN, surgery, length of stay, etc BUT ICU climate has changed, better antiobiotic stewardship, less TPN etc

How to predict development of invasive candidiasis

  • Colonisation index – number of positive sites/total sites
  • Candida score – surgery, TPN, sepsis
  • Clinical prediction rule

Key messages

  • Antifungal stewardship
  • Untargeted antifungal treatment complex issue
  • Optimal pt population for prophylaxis difficult to identify
  • Recurrent intestinal leakage after surgery most obvious indication
  • Major impact of antifungal strategies remain to be demonstrated
  • Invasive disease incidence lower – changing risk factors?

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References:

Antifungal agents for preventing fungal infections in critically ill adults and children with a normal number of neutrophils in the blood

Clinical prediction rules for invasive candidiasis in the ICU: ready for prime time?

Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure. The EMPIRICUS Randomized Clinical Trial 

Clinical Practice Guidelines for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America 

 

Invasive candidiasis: current therapy in critical care (H Qiu)

Major difficulty is differentiating colonisation vs infection

Fungal infection is under diagnosed – post-mortem findings

Candida albican is the major species BUT the situation is changing: Development of flucanozole resistance is increasing in countries e.g. China

Prediction scores have high negative predictive value but poor positive predictive value

Take home message

  • Move common that thought
  • High mortality
  • Earlier therapy not easy
  • Get it right first time (echinocandins)
  • De-escalate
  • Resistance if under treated/dosed

References:

ESCMID† guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients

 

Severe dengue fever: the role of the intensivist (CM Chen)

Global burden – increase population, global warming, rapid urbanisation

Tropical climate

Spread by the female Aedes mosquito

Dengue classification 1997 – undifferentiated, dengue fever, dengue hemorrhagic fever; updated in 2009 into classes A, B and C

Diagnosis – serology

Dengue fever can cause multi-organ failure

Co-current bacterial infection not uncommon

References:

WHO Dengue guidelines 2009

Critical care for dengue in adult patients: an overview of current knowledge and future challenges

EuAsia 2017 Day 2: Spontaneous breathing and ARDS

Role of NIV (M Antonelli)

Mechanism of VILI: role of transpulmonary pressure (PL)

PL = Paw (ventilator) – Ppl (muscle)

Low Vt is almost impossible to obtain during NIV

The problem with ARDS trials….

  • Different disorders lead to ARDS
  • Different pts respond differently

Recognition of ARDS by clinicians is poor especially mild ARDS

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References

Fifty Years of Research in ARDS. Spontaneous Breathing During Mechanical Ventilation – Risks, Mechanisms &Amp; Management

Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome

The LUNG SAFE study: a presentation of the prevalence of ARDS according to the Berlin Definition! 

 

HFOT (CY Lim)

Physiological effects

  • Warmth and humidity in upper airways
  • Reduction in inspiratory resistance
  • Positive pressure in nasopharynx
  • Washout of nasopharyngeal dead space

HFNC for ARDS

  • Hypoxia
    • increase end-expiratory volume
    • help homogenise distribution of ventilation
  • High dead space fraction
    • increase tidal volume
    • decrease Vd/Vt

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References

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients

Nasal highflow improves ventilation in patients with COPD 

 

The dark side of spontaneous breathing in ARDS (T Yashida)

Harm of spontaneous breathing

  • Better oxygenation with paralysis
  • Less inflammation
  • Less work of breathing after paralysis
  • Improve mortality with early paralysis (in severe ARDS)

Pt may have a PS 5 and PEEP of 5 but with strong effort, can generate Vt of 12ml/kg –> barotrauma

The beneficial effects of spontaneous breathing is seen only in mild ARDS

Mechanism of harm

  • Large Vt and Pl
    • The negative pressure of SV can lead to high Pl
  • Pendelluft
    • Injured lung do not have homogenous ventilation
    • Worsening inflammation
  • Worsening capillary leak
  • Asynchrony

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References

Spontaneous Effort Causes Occult Pendelluft during Mechanical Ventilation

Fifty Years of Research in ARDS. Spontaneous Breathing During Mechanical Ventilation – Risks, Mechanisms & Management