Category Archives: Surgery

PODCAST – Sepsis in Low Resource Environments with Flavia Machado

#LIVES2018 Podcast

Aidan Baron Interviews Professor Flavia Machado after her lecture on Sepsis in Low Resource Environments with a particular focus on Brazil and Latin America.

Flavia Machado is professor and head of the Intensive Care Session of Anesthesiology, Pain and Intensive Care Department at the Federal University of São Paulo in Brazil. This year she received an honorary membership of ESICM for her global leadership in intensive care research at LIVES 2018.

She is one of the founders of the Latin America Sepsis Institute–LASI. She was the president between 2008-2011, vice president between 2012-2015 and is currently its CEO. LASI is devoted to awareness raising, quality improvement and coordination of multicenter studies in sepsis field. She is part of the executive board of the Global Sepsis Alliance and the executive committee for the World Sepsis Day. She serves on the 2012 and 2016 board of the Surviving Sepsis Campaign International Guidelines. She has been a member of the International Sepsis Forum (ISF) council since 2014. She is also a member of both the Executive and Scientific Committee of the Brazilian Research in Intensive Care Network-BRICNET.

International Sepsis Forum at #LIVES2018

Play the podcast below

 

 

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Big Data in ICM research: Reality or the future? #LIVES2017

The tech lounge opened on Monday morning with a bang – loads of giants in the field chatting and presenting in an informal zone.  Super busy, people everywhere –  standing room only!

Leo Celi from MIT gave an inspirational talk about data – its impressive what he has set up.

He recommends this (free online) book that he and others wrote if you are interested in the field (http://www.springer.com/gp/book/9783319437408) and he is clearly passionate about getting people involved and doing “big data” properly – hackathons and datathons galore in europe and abroad (plug alert – if you are interested in them see this one in London in December with Mervyn Singer et al.)

Another good editorial that Leo recommended to read is this one in the NEJM (not paywalled!) http://www.nejm.org/doi/full/10.1056/NEJMra1614394

He made the point that AI has come a long way, but we need to be careful to do it properly so as not to over sell the field, which is still in its infancy.

Successes he quoted include Articial intelligence diagnosing diabetic retinopathy but he was scathing about IBMs Watson – calling it a “digital canary” and the AI equivalent of a mechanical turk (a sham chess “computer” with a human inside) His point was that it is not truly harnessing data on its own, and so should not be claimed that it is – although important on the way to doing that.

Then Derek Angus gave a really easy to understand run through of how big data and RCTs can coalesce and we can really harness the power of data to help us do what we do.

Derek talked about two trials that are currently running “within” the electronic health records systems in the USA, which cost 10% of the equivalent traditional RCT so you can see why these techniques are attractive.

His concept is to remove the bias from randomisation alteration by clinicians (based on initial results of studies) and handing that over to computers in a concept known as “response adaptive randomisation”.  I have tried to capture it in this thread:

Great stuff!

An exploration of what questions big data might answer followed from Theodoros Kyprianou.  What is big data?:

He took the gathered crowds through the different ways machine learning can occur on the ICU (and in healthcare generally); to recap there is

Supervised learning – data given to computer and outcomes known, computer tries to sort data to predict outcomes

Unsupervised learning – data given to computer and outcomes not known, computer tries to sort data into its own groups

Reinforcement learning – computer given reward structure if certain outcomes met – aims to maximise reward and discover easiest route to outcome

He talked about the sort of things where this might be useful to clinicians – for example in making simple choices and decisions, or creating healthcare and illness classifications or even making diagnoses.  An interesting possibility was letting machine learning do the “physiological fine tuning” on a unit.

Overall this session was really fun and it was great to hear from all the speakers on how machine learning is being used currently but also “future gaze”; inspiring to think what our units and hospitals might look like one day!

ESICM LIVES 2017 NEXT Day – ECMO #LIVES2017

ECMO Course

Session 1 – Antonio Pesenti, Refractory Hypoxaemia Therapuetic Strategies

Before deciding on support, first need to know what targets. One might be PaO2? If you climb up a mountain it’s low? Is this important – not according to Grocott in NEJM 2009 where low levels were compensated for by higher Hb.

Rx hypoxia broadly divided as follows

  1. Treat cause – antibiotics, thrombolysis, etc, etc
  2. Increase FiO2
  3. Reduced atelectasis – PEEP
  4. Increase pulmonary blood flow
  5. Reduce venous admixture – ECMO

Reabsorption atelectasis complicates high FiO2 administration.

PEEP prevents collapse = recruitment manoeuvres are needed to open collapsed lung. Indeed main difference between traditional IPPV & HFOV/APRV is high airway pressure – theory being more recruitment AND retention.

Don’t forget effects of heart + shunt upon O2 but iNO doesn’t work.

The benefits of proning extend beyond its effects on PaO2 – failure to improve this variable does not mean you should stop doing it.

Longer term, hypoxemia is a risk factor for long-term neuropsychological impairment but HYPEROXIA IS BAD.

 

Session 2 – Jan Bakker, Haemodynamic effects upon ECMO

Very variable! Limited prospective scores – ENCOURAGE might be useful for VA, or clearing fluid balance on day three but in essence little evidence.

When considering you need to ask:

  • What other support have you got?
  • What configuration are you using?

Peripheral VA-ECMO can significantly increase after load – first consider dilators, then increase forward flow whilst remember to treat acidodsis/anaemia. If that doesn’t work, add an IABP.

With VV-ECMO, RV afterload will fall with PVR effect because of beneficial effects upon CO2/PAO2.

 

Session 3 – Weaning from ECMO Giacomo Grasselli

No science to this – lack of definite criteria, indications from guidelines and local protocol and personal experience

Four scenarios

  1. wean ECMO, then vent
  2. Emergency discontinuation, e.g. bleed
  3. First wean vent, then ECMO
  4. Withdraw

Weaning from VV is weaning gas flow – you don/t need to reduce flow

Weaning GF increases muscle effort and needs vent support 

ELSO guidelines

You need haemodynamic stability as well as respiratory improvement. Measure oxygen delivery – the target is tissue oxygenation NOT PaO2.

How long do you keep the gas off? – Karolinska say 4 hours

Some authors propose leaving cannulae in place for put to 48 hours flushed with heparinised solution – practice VARIABLE

How to decannulate VV?

  • Stop/reduce heparin
  • Put purse string around insertion cannula
  • Clamp lines
  • Stop pump
  • Remove pipe allowing small amount of leakage to red air embolism
  • Manual compression 20 min for venous and 30 min for arterial.
  • Close monitoring distal perfusion for arterial and consider  vascular ultrasound in both as high incidence of clot or injury

 

Keynote – Michael QUINTEL, 50 years of ECMO

ECLS first developed by John Gibbon and Mali in 1936 in response to sudden death young patient with PE and first used in ORD for ASD repair May 1953

First trials negative – but badly done – so perhaps can be better interpreted as even if you do ECMO badly, you don’t kill everyone…

CESAR trial goo.gl/T6tdEL

First oxygenators bubble before developed hollow fibre oxygenator

The development of heparin-coated circuits allowing limiting APTT was one the major steps in reducing morbidity and mortality

Single centres such as Michigan have led the way – now more adult/paed, less neonates

Then H1N1 prompted exploration http://ja.ma/2xp301Q

H1N1 make worldwide excessive use of the technology but there is no new real data.

Reasonable data about risk/benefit ratio does not exist. Cerebral micro emboli are universal. 85% get DVT.

Is informed consent even possible?

 

Pro: Is ECMO always an Option? Steffen Weber-Carstens

UK evidence summarised by @CochraneUK in 2015

Similar International Consensus Position Paper by Coombes and colleagues on what defines an ECMO centre

Triage essentially as duration IPPV significant risk factor of deaths.

Con: Giacomo Bellani 

In one series, 87% of referrals had at least one relative contraindication

25% of patients in CESAR didn’t get it

EOLIA trial has not reported and is ongoing – we are in the infancy of what we know

16% rates of head bleed

20% nosocomial infection

Why use more resources when you can achieve the same thing with less? LungSafe shows we still don’t get optimium PEEP, NMBA, fluid balance and supportive care in ARDS.

 

Peri-operative Right Ventricular Failure

A problem that can clearly be served up to us all. But we’re more familiar with LV failure. So what shod we do? Read on…

Sascha Treskatch

  • The incidence is low (thankfully)
  • Predispositions
    • Cardiopulmonary bypass
    • Pulmonary hypertension
    • RV functional reduction
    • Hypervolaemia (!)
  • Consider what the RV function is like when assessing if the LV is going to be fluid responsive. Article here.
  • Guidelines recommend using echo. assessment first before more invasive measure used (of course)
  • 2 good articles telling us lots about the RV , and what gets done by us to worsen its function I and II
  • A nice little algorithm presented for management

Summary management

  • Adequate preload
  • Maintain a good MAP to ensure (right) coronary perfusion
  • Support contractility
  • Reduce PVR (PDE II inhibitors)
  • Transfer out (potentially for extracorporeal support)
  • Another little algorithm about what exactly to do (non-echo-based)

 

Some food for thought, and some guidance to think about at least. I think I will have a better idea of what to do, perhaps in what order now, and definitely think more about the RV/LV interactions.