Category Archives: Refresher course

Critical Care Refresher Course: Trauma and Surgery

GI Bleed (Kumar)

What is a massive GI bleed?

  • Bleeding resulting in CVS collapse
  • mortality up to 40%
  • over 75% due to upper GI bleed (lower GI bleed mortality 2%)

Etiology

  • Ulcers (Duodenal > Gastric)
  • Gastritis
  • Varices
  • Oesophagitis

Team: Gastroenteritis, Surgeon, Interventional Radiologists

Pharmacotherapy

Acute pancreatitis (Marshall)

Pancreatitis is a chemical burn of the retroperitoneum

Incidence 10-80/100,000

Mortality 10-25%

Pathophysiology

  • Fluid collection, ascites
  • Pseudocyst
  • Fat necrosis

Severity scores –

Resist antibiotics

No other intervention except PATIENCE!

Early surgery for pancreatitis do badly.

Critical Care Refresher Course: Infection and Inflammation

Antibiotic PK/PD (Rello)

Knowledge of PK/PD on ICU improves safety and efficiency

  • Penicillins & Cephalosporins – T>MIC is most important PK/PD parameter (maintain about >50%)
  • Aminoglycosides & quinalones – Most imporatnt parameter is Peak/MIC > 8-10 and a 24hr AUC/MIC >100-125

When antibiotics ‘fail’; what is the solution?

  • Ensure sensitivity correct (liaise with microbiologist)
  • Improving the probability of positive outcomes i.e. improve efficacy and limit resistance
    • Alter duration of infusions
    • Combination (Synergies)
    • Increase peak concentration

References

Use of meropenem by continuous infusion to treat a patient with a Bla(kpc-2)-positive Klebsiella pneumoniae blood stream infection. – https://www.ncbi.nlm.nih.gov/pubmed/21859337

Efficacy of high-dose nebulized colistin in ventilator-associated pneumonia caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. – http://www.ncbi.nlm.nih.gov/pubmed/23132092

Update on Sepsis (Marshall)

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) – http://jama.jamanetwork.com/article.aspx?articleid=2492881

Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. – https://www.ncbi.nlm.nih.gov/pubmed/26414292

Recognise!

Resuscitation – Keep it simple and assess the response to therapy

  • oxygen – target SpO2 92-95%
  • intravenous fluids – target: Systolic BP>100, HR<100, UO>30ml/hs, CVP>8
    • ITS THE RESPONSE THAT IS CRUCIAL
  • vasoactive drugs

Diagnose infection

  • site – history, examination, imaging
  • pathogen – blood cultures and targeted cultures

Treat infection

  • early antibiotics

?immunomodulatory therapy

  • cytokine inhibition
  • endotoxin neutralisation

Supportive care on ICU

  • support organ dysfunction
  • minimise harm
  • de-escalate wherever possible
  • anticipate complication

Fungal Infection (Gruber)

International Study of the Prevalence and Outcomes of Infection in Intensive Care Units http://jama.jamanetwork.com/article.aspx?articleid=184963

Aspergilus

Candida

Decreasing incidence of albicans with increasing glabrata

Recent alert on Candida auris – http://www.cdc.gov/fungal/diseases/candidiasis/candida-auris-alert.html

Diagnosis of invasive candidiasis in the ICU – https://annalsofintensivecare.springeropen.com/articles/10.1186/2110-5820-1-37

Candida score – https://annalsofintensivecare.springeropen.com/articles/10.1186/2110-5820-1-50

Critical Care Refresher Course: Respiratory and Airways Management

Management of Tracheostomy (Waldmann)

EPIC Study 1992 – 12% of ICU pts had tracheostomy insitu

On the Right Trach – http://www.ncepod.org.uk/2014report1/downloads/OnTheRightTrach_Summary.pdf 

NAP4 – http://www.rcoa.ac.uk/document-store/nap4-executive-summary

Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes – http://rc.rcjournal.com/content/59/6/895.full

Meta-analysis comparison of open versus percutaneous tracheostomy. – https://www.ncbi.nlm.nih.gov/pubmed/17334304
TRACMAN trial – https://www.ncbi.nlm.nih.gov/pubmed/23695482 

Tracheostomy Global collaborative – http://globaltrach.org/

Protective Lung Ventilation (Gattinoni)

Aim of resp support is to buy time whilst minimising damage

Modeling the time-course of ventilator-induced lung injury: what can we learn from interspecies discrepancies? http://link.springer.com/article/10.1007/s00134-011-2394-y

Lung anatomy, energy load, and ventilator-induced lung injury https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679691/

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome — http://www.nejm.org/doi/full/10.1056/NEJMsa1410639#t=article

 

Management of bariatric patients (Rubulotta)

WHO interactive map on epidemiology of obesity – http://www.ncdrisc.org/map-obesity-prevalence.html 

Neck circumference – height ratio in predicting sleep-related breathing disorder https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773632/ 

STOP-BANG for OSA screening – http://www.stopbang.ca/osa/screening.php

Ventilation strategies in obese pts undergoing surgery: quantitative systematic review & meta-analysis http://bja.oxfordjournals.org/content/109/4/493.full

Protective Ventilation With Higher Versus Lower PEEP During General Anesthesia for Surgery in Obese Patients (PROBESE) protocols – https://clinicaltrials.gov/ct2/show/NCT02148692 

High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60416-5/abstract?rss=yes 

Critical Care Refresher Course 2016: Cardiovascular

Pulmonary Hypertension (Rothen)

Pulmonary circulation

  • High flow, low pressure, low vascular resistance
  • Determinant of vascular resistance
    • intra or extraluminal obstructions
    • autonomic tone
    • hypoxia, hypercapnia (acidosis)
    • circulating vasoactive substances
    • blood viscosity
  • Interdependence between RV and LV
    • RV dilatation causes septal shift
  • RV adaptation to large increases in pressure is limited

Management of pulmonary hypertension in the ICU

  • Avoid/treat exacerbating factors
    • hypoxaemia/hypercania
    • acidosis, hypothermia, hypotonia, hypervolaemia
  • Consider vasodilators
    • inhaled prostacyclin, nitric oxide
    • PDEi
    • Dobutamine, milrinone, levosimendan
  • BE SUSPICIOUS AND ACT EARLY

 

ESC/ERS Guidelines – http://eurheartj.oxfordjournals.org/content/early/2015/08/28/eurheartj.ehv317

Clinical management of pulmonary hypertension – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4452016/

Doppler-defined pulmonary HTN in medical ICU patients: Retrospective investigation of risk factors & mortality https://www.ncbi.nlm.nih.gov/pubmed/22034595

Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology – https://www.ncbi.nlm.nih.gov/pubmed/24355638

Right heart failure (Vieillard-Baron)

Summary

Formal diagnosis of RV failure is difficult

  • Clinical signs – significant congestion, shock
  • Monitoring – Severe RV dilatation, Decreased CO, CVP>PAOP, pulse pressure variation
  • Biological markers – decreased S(c)VO2, Increased lactate, Increased AP

Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. – https://www.ncbi.nlm.nih.gov/pubmed/26650055

ACUTE AND CHRONIC HEART FAILURE ESC Clinical Practice Guidelines – http://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239778/

Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome. – https://www.ncbi.nlm.nih.gov/pubmed/22511135

Echo–Doppler Demonstration of Acute Cor Pulmonale at the Bedside in the Medical Intensive Care Unit – http://www.atsjournals.org/doi/full/10.1164/rccm.200202-146CC#.V-9iYZN9634

Is ARDS usually associated with RV dysfunction or failure – https://www.ncbi.nlm.nih.gov/pubmed/7790603

Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation – http://icmjournal.esicm.org/journals/abstract.html?v=0&j=134&i=0&a=4326_10.1007_s00134-016-4326-3&doi=

Outcome prediction in sepsis: Speckle tracking echo based assessment of myocardial function – https://ccforum.biomedcentral.com/articles/10.1186/cc13987

Valvular heart disease (Maggiorini)

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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease – http://content.onlinejacc.org/article.aspx?articleid=1838843

Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement – www.nejm.org/doi/full/10.1056/nejmoa1200384#t=article

4-Year Results of a RCT of Percutaneous Repair Versus Surgery for Mitral Regurgitation – http://content.onlinejacc.org/article.aspx?articleID=1687961