ESICM Webinar – FOCUS on #POCUS

*This webinar was kindly sponsored by GE*

We would love to hear from you and any feedback/questions would be welcomed. OR if you want to find out more about #POCUS fellowships……

The presentation….

https://www.icloud.com/keynote/0TjTY6dm-GTqkL_YCFewLu4kA#ESICM_webinar

Reference list

What is #POCUS

Lichtenstein D, van Hooland S, Elbers P et al. Ten good reasons to practice ultrasound in critical care. 

Lichtenstein D and Mezière G (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure. The BLUE-protocol. 

Perera P, Mailhot T, Riley D et al. The RUSH exam: Rapid ultrasound in shock in the evaluation of the critically ill. 

Lichtenstein D.A. Lung Ultrasound as the First Step of Management of a Cardiac Arrest: The SESAME-Protocol. In: Lung Ultrasound in the Critically Ill. Springer, 2016 Cham

Training in #POCUS

Malbrain MLNG, De Tavernier B, Haverals S et al. Executive summary on the use of ultrasound in the critically ill: consensus report from the 3rd Course on Acute Care Ultrasound (CACU). 

Mayo P, Beaulieu Y, Doelken P et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. 

Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultrasonography. 

Wong A, Galarza L and Duska F. Critical Care Ultrasound: A systematic review of international training competencies and program. 

Galarza L, Wong A and Malbrain M. The state of critical care ultrasound training in Europe: A survey of trainers and a comparison of available accreditation programmes. 

Future of #POCUS

Robba C, Goffi A, Geeraerts T et al. Brain ultrasonography: methodology, basic and advanced principles and clinical application. A narrative review. 

Aitkinson P, Beckett N, French N et al. Does point-of-care ultrasound use impact resuscitation length, rates of intervention and clinical outcomes during cardiac arrest? A study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. 

Feng M, McSparron JI, Kien Dt et al. Transthoraccic echocardiography and mortality in sepsis: analysis of MIMIC-III database.

If you are REALLY interested in pushing the limits of ultrasonography in critical care … https://thinkingcriticalcare.com/

Recommended textbooks

TTM @ #EuAsia19

Optimal depth, timing and duration based on recent clinical trials (K Sunde)

Cardiac arrest is a complex disease

  • several different causes (many untreatable, irreversible, extreme challenging)
  • large heterogeneity
  • challenges the system due to the limited/crucial time-intervals (hypoxia/extreme ischemia)
  • large differences in quality of care within and inbetween systems (both during ALS and in post resuscitation care)
  • very high mortality

Depth and Timing

ILCOR Statement 2003 –

Unconscious adult patients with spontaneous circulation after out-of hospital cardiac arrest should be cooled to 32-34°C for 12-24 hrs when the initial rhythm was VF.

For any other rhythm, or cardiac arrest inhospital, such cooling may also be beneficial.

Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.

  • timing, speed and duration of hypothermia had no impact on outcome!

Confounding aspects regarding early/fast cooling

  • the lack of protection against a drop in core temperature is due to a larger and deeper brain injury! (link)
  • If you are really “dead” you are colder and it is very easy to cool you fast! (link)

Intra-Arrest Transnasal Evaporative Cooling: A Randomized, Prehospital, Multicenter Study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness) link

Duration of TTM

Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest

Prolonged targeted temperature management in patients suffering from out-of-hospital cardiac arrest

Conclusion

  • Cardiac arrest is complex, with large heterogeneity and very high mortality
  • Large differences in quality of care within and inbetween systems
  • Concerning pathophysiology and TTM: depth, speed and duration impacts on the reperfusion injury/brain injury
  • We are concluding based on pragmatic trials not optimizing the intervention tested or considering the ongoing pathophysiology!
  • Outcome assessment: cognitive function/QoL years after the arrest!

Haemodynamic Management During Targeted Temperature Management (Huang CH)

Multiple reasons for haemodynamic instability post-cardiac arrest

Haemodynamic Response Correlated to Outcome – Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest.

Cardiovascular Response & Haemodynamic Changes In Hypothermia Treatment

  • Changes in CV β-adrenoceptor (reduced response)
  • Bradycardia
  • Increase in stroke volume
  • Reduced intravascular volume during hypothermia is by 10– 35%

Lower heart rate is associated with good one-year outcome in postresuscitation patients (link)

Survivors Have Higher Mean Arterial Pressure (link)

Lowest value of DAP over the first 6 h after ICU admission for predicting unfavourable neurological outcome at 3 months (link)

Postresuscitation hemodynamics during therapeutic hypothermia after out-of-hospital cardiac arrest with ventricular fibrillation: A retrospective study

Taiwanese Protocol