Sketchnotes at LIVES 2019

This year I had the privilege of joining the ESICM Social Media team as a sketchnote artist. Combining live sketchnotes with a passion for your own specialism brings a whole world of opportunities for engagement and communication – I’ve enjoyed it immensely and I would recommend it to anyone wanting to increase their GCS during a marathon conference! Here are some of the highlights from LIVES 2019:

Annemiek Nooteboom: The Importance of Body Language. A tour de fource of “fun, stereotyping and plagiarism” (her words, not mine!) set alongside a stirring nightclub-style soundtrack, Annemiek Nooteboom demonstrated dominant and subservient body language. We were surprised to see Prof Armand Girbes take the counter-role; it was all a bit real. Key lessons: three phases of training include (1) fake it till you make it – don’t act invisible, (2) multiple personalities – as the boss, sometimes it’s your job to look the part, (3) the Godfather phase – in official leadership, you *must* adopt non-threatening body language to counteract the inevitable intimidation and fear that such a role engenders.

Intoduction and Highlights – Prof Armand Girbes and a pair of magicians… Congratulations are in order for the ESICM leadership, as they demonstrate further steps forward on the path to diversity and transparency. The percentage of female speakers is at its highest yet (27%). It’s possible they’ve been using magic – our entertainers were able to woo the audience “Pen & Teller” style. Most striking was the tic-tac-toe they asked the audience to choose each next move with, only to reveal on the flip-side of the game that their tile choices had spelled out the conference logo…

Subsequently I visited the NEXT Lounge for aspiring young intensivists for a whistle-stop tour of acid-base physiology. Eric Hoste illustrated the basics in this high-tech “blackboard” session, replete with gems of history and clinical applicability. He did well to create an interactive atmosphere with good to-and-fro between him and participants.

In the Tech Lounge, Steve Harris unveiled “How to turn your data into gold.” For me, the most profound insight he stressed was that clinicians may rarely ever be true data science methodology experts. However, clinicians can offer the unique and crucial advantage of being able to ensure data is meaningful for the patients we serve. This is why it’s so important to stay close to your data and ensure it’s trustworthy.

The NEXT lounge offered a thought-provoking debate into the nature of religion and ethics in providing good care. Sharon Einav described some of the profound differences in providing end of life care, in particular, in legal sanctions against withdrawal of life sustaining therapies. A helpful member of our MDT in the future is the religious and cultural anthropologists, assisting in the navigation of these highly complex issues. Furthermore, how far do we distance our own personal ethical code from that of the patients, and what implications does this have – e.g. moral distress in extended futility? A huge set of unanswered questions for consideration in the future of global ICU – with Roland Francis, Sharon Einav, Burcin Halacli and Stefan Schaller.

Peter Pickkers presented the findings of this phase 2 study into a beta-HCG derivative, thought to have immunomodulatory roles in line with the effects of normal pregnancy. An infusion of the drug EA-230 during cardiac surgery was associated with better creatinine clearance and less AKI, as well as a slightly shorter length of stay. Other mechanistic questions – such as an effect on IL-6 or GFR – were negative. It was a pleasure to hear about this group’s work. https://www.ncbi.nlm.nih.gov/pubmed/30724734

I was thrilled to have attended the Global Intensive Care working group meeting, having heard about it but been unable to see it advertised. After picking up the time and date on the grapevine, I had the opportunity to hear about the ongoing early work. Most excitingly, the ALIVE sepsis course has launched in Kampala, Uganda with Mervyn Mer and Arthur Kwizera. It’s set to travel to three other locations in the coming months. It is the first of its kind; one day of mini-modules and another day of bedside teaching in a LMIC setting. Amongst the remaining activity, I was excited to see the publication of the freely available Springer volume, Sepsis Management in Low Resource Settings: https://www.springer.com/gp/book/9783030031428

 

Members of the Global ICU working group included Tim Baker and Carl Otto Schell. They have completed the Critical Illness Prevalence and Outcomes Study (CRISPOS) in Sri Lanka, Sweden and Malawi, demonstrating the point prevalence of several markers critical illness. Furthermore, they have shown a mortality benefit to Vital Signs Directed Therapy where lives were saved “by a piece of paper.” Re-examining the paradigm of critical care in resource limited settings, they continue to develop concepts addressing the need to design services that save lives rather than simply emulate existing strategies.

Georg Trummer discussed the use of ECMO in cardiac arrest as truly “buying time”. Perhaps eCPR should be part of a new chain of survival, opening a new window of opportunity? Experiments in pigs have shown excellent outcomes after a full twenty minutes of proper down time, he tells us. It is possible that eCPR could extend the golden hour, but the huge challenges in research, logistics etc make it difficult to see this should be implemented while questions remain unanswered. I note that Alberquerque, New Mexico, has just now set up the first eCPR service in the USA, arguably.

Lastly, Dominique Benoit discussed “Quality of Life as the Ultimate Goal?” His talk examined aims in treating the very elderly, so often a palliative population. On the other hand, these patients may be more accepting of poorer outcomes. He quoted the 20th century moral theologian George Dunstan, “the success of intensive care is not to be measured only by the statistics of survival, as though each death were a medical failure. It is to be measured by the quality of lives preserved or restored, the quality of the dying of those in whose interest it is to die and by the quality of relationships involved in each death.” https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2044.1985.tb10852.x And in addition, he discussed ethical leadership, “being able to talk to anyone about anything”, composed of humility, vulnerability, altruism and courage, among other things. This was a moving and stirring talk and certainly a huge encouragement to this intensive care doctor.

Trauma: which fluid? when?

Which fluids need to be administered in the trauma patient? when? In trauma patients, fluid resuscitation aims at restoring circulating volume to prevent cardiac arrest due to severe hypovolemia, and at achieving a satisfying level of mean arterial pressure to ensure adequate tissue perfusion, limiting coagulation disorders. Lot of potential secondary adverse effects could be associated to  fluid resuscitation, ie hemodilution, acidosis & coagulation disorders.

In this infographic,  the concepts of permissive hypotension and remote damage control resuscitation RDCR, and some notes on on crystalloids, colloids & blood products.  

graphics by Marta Velia Antonini @FOAMecmo

content based on the talk given by Sophie Hamada, ICU Hôpital Bicêtre University Paris Sud, Groupe Traumabase.EU during the Trauma & surgery session  of the EDIC I Refresher Course at #LIVES2019 Congress

 

Consolidation on Lung Ultrasound

The 7 principles of Lung Ultrasound in the Critically Ill LUCI and echographic diagnosis of lung consolidation in this LIVES2019 infographic!

1 – a simple equipment is the best

2 – thorax is a mingling of air (gas) and water (fluids)

3 – lung is the most voluminous organ: here some advices on where to apply the probe?

4 – all arises from pleural line

5 – LUCI is the science of artifacts

6 – Lung: is a vital organ

7 – Most life-threatening disorders reach the wall and and have usually extensive surface

Why and how looking for consolidation?? here the Blue protocol with its profiles and some notes on the Pink protocol. How to distinguish between translobar and non translobar consolidation? Do we have an obstructive atelectasis or it’s just compression? take a look…

graphics by Marta Velia Antonini @FOAMecmo

content based on Daniel Lichtenstein masterclass at #LIVES2019

 

The nurse is the cornerstone of nutrition delivery (Nestle Health Science sponsored session)

Nurse driven metabolic care

(Mette Berger)

Pts with lower cumulative protein and energy deficits are 3x more likely to go home

ICU is a changeful environment – multiple factors preventing pts from being fed to prescribed goals, but the MAIN problem is often getting EN prescribed / re-started

Nurse-driven protocols (e.g. insulin infusion, catheter infection prevention, resuscitation etc) have a track record of working well!

–> Can Nutrition be nurse-driven, independent of doctors?

  • focus on glycaemic control
  • initiation / resumption of feeding
  • tube placement / control
  • monitoring of delivery

Clear protocols listing roles with describing their responsibilities

Metabolism and nutritional needs vary through the phases of critical illness / during rehabilitation

Nutritional Risk Score (NRS) to identify pts at risk of nutrition-related complications

Glycaemic control

  • demonstrable improvement in tight glucose control when transferred to the care of nurses
  • nurse immediately available to assess and respond to BMs

Initiation of Feeding

  • gastric residues may prevent feeding first 48 hrs post-op
  • can check using ultrasound
  • try pro kinetics during this time

Tube placement

  • tube checking protocols

Monitoring delivery

  • ESPEN guidelines suggest progressively increasing feeding; aggressive early feeding risks hurting sick gut

  • do NOT aim to cover prescribed feeding goals in the first week
  • nurse is well-positioned to detect signs of pt tolerating / not tolerating feed
  • Beware absent stools – Encourage emollients and fibres in feed upon initiation of feeding – this should not cause significant diarrhoea

 

**Metabolic rationale for starting slow:

Endogenous glucose production is stopped by eating (in healthy people) – this mechanism is lost in critical illness, and therefore there is continuous endogenous glucose production of 200-300g glucose / day = 800kcal even if EN is commenced

–> therefore, starting with a full feed will result in overfeeding

 

A nursing perspective on nutrition

(Beatrice Jenni-Moser, M-M Jeitziner)

Nutrition has a significant impact on a pt’s ability to respond to medical / nursing treatment

Large variation in nursing practices around nutrition (availability of nutritional guidelines, knowledge and leadership)

Nutrition is often prioritised lower than other care needs

** pt’s relatives are often concerned about having ‘enough to eat’

New paradigm of rehabilitation: Start early, not at the end of medical treatment

–> the same should apply to nutrition – need an MDT approach

 

Quality project

  • Setting: Interdisciplinary ICU / 37 beds
  • Approx 4000pts / year
  • Length of stay: 2.4days (mean); 8% of pts stay 7days or more

Aim: Overview of nutrition, diarrhoea and constipation

Method: Chart reviews

Sample: (Neurological disease 40%)

2018 – 97 pts, mean age 61.4 (16-90)

2017 – 93 pts, mean age 60.2 (21-94)

— Protocol designed around existing guidelines for patients and also potentially difficult pts

  • EN as the standard approach, early EN within 48 hrs
  • Continuous rather than bolus EN
  • Contraindication to oral, EN –> PN should start within 3-7 days
  • Early and progressive PN is better than starvation
  • After 3 days, caloric delivery can be increased up to 80-100%

Nutritional Assessment: In-depth evaluation of objective and subjective data related to an individual’s food and nutrient intake, lifestyle, medical history

Combine with Frailty scale in every pt for a baseline frailty score (not just in the older pts / long stay)

Take home message: ICU nurses are in a unique situation to take an active role in promoting the best nutritional outcomes to the pts

  • interprofessional nutrition education
  • nutritional screening and assessment
  • using standardised guidelines / protocols
  • evaluating nutrition support