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%)


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

Team: Gastroenteritis, Surgeon, Interventional Radiologists


Acute pancreatitis (Marshall)

Pancreatitis is a chemical burn of the retroperitoneum

Incidence 10-80/100,000

Mortality 10-25%


  • 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


Use of meropenem by continuous infusion to treat a patient with a Bla(kpc-2)-positive Klebsiella pneumoniae blood stream infection. –

Efficacy of high-dose nebulized colistin in ventilator-associated pneumonia caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. –

Update on Sepsis (Marshall)

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) –

Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. –


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
  • 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



Decreasing incidence of albicans with increasing glabrata

Recent alert on Candida auris –

Diagnosis of invasive candidiasis in the ICU –

Candida score –

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 – 

NAP4 –

Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes –

Meta-analysis comparison of open versus percutaneous tracheostomy. –
TRACMAN trial – 

Tracheostomy Global collaborative –

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?

Lung anatomy, energy load, and ventilator-induced lung injury

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome —


Management of bariatric patients (Rubulotta)

WHO interactive map on epidemiology of obesity – 

Neck circumference – height ratio in predicting sleep-related breathing disorder 

STOP-BANG for OSA screening –

Ventilation strategies in obese pts undergoing surgery: quantitative systematic review & meta-analysis

Protective Ventilation With Higher Versus Lower PEEP During General Anesthesia for Surgery in Obese Patients (PROBESE) protocols – 

High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial – 

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


ESC/ERS Guidelines –

Clinical management of pulmonary hypertension –

Doppler-defined pulmonary HTN in medical ICU patients: Retrospective investigation of risk factors & mortality

Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology –

Right heart failure (Vieillard-Baron)


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. –

ACUTE AND CHRONIC HEART FAILURE ESC Clinical Practice Guidelines –

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine –

Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome. –

Echo–Doppler Demonstration of Acute Cor Pulmonale at the Bedside in the Medical Intensive Care Unit –

Is ARDS usually associated with RV dysfunction or failure –

Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation –

Outcome prediction in sepsis: Speckle tracking echo based assessment of myocardial function –

Valvular heart disease (Maggiorini)

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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease –

Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement –

4-Year Results of a RCT of Percutaneous Repair Versus Surgery for Mitral Regurgitation –