Category Archives: Refresher course

Critical Care Refresher Course: Trauma and Surgery

Polytrauma Patient (Duranteau)

Early mortality is usually due to uncontrolled haemorrhage. Late mortality and disability is due to brain injury and multiorgan failure

Control of haemorrhage

  • Low volume volume resuscitation – SAP 80-90mmHg until bleeding stopped; MAP > 80mmHG in TBI. vaopressor may have role (animal models)
  • Trauma-induced coagulopathy: multifactorial, complex and dynamic. Use TEG
  • Euro recommends plasma:red cell ratio of at least 1:2
  • Plts > 50 ( >100 if ongoing bleeding or TBI)
  • Fibrinogen target of between 1.5-2g/L
  • Early transexamic acid (1g load, followed by 1gm over 8)

 

References

European guidelines of major trauma

Damage control haematology

Trauma-Associated Severe Haemorrhage (TASH) Score

PROPPR Trial

CRASH-2 Trial

 

Perioperative Intensive Care Medicine  (Hiesmayr)

Post op issues on the ICU

  • Volume instability
  • Bleeding – surgical and anaesthetics (lines)
  • Fever
  • Residual anaesthetic drugs
  • Delirium

Know the patient (premorbid state) and know the surgery

Types of surgery and specific problems

  • Vascular – comorbidities, bleeding, ischaemia
  • Ortho – fat embolism, bone-cement cardiac event
  • Solid organ transplant – infection, graft failure, vascular complications
  • Neurosurgery – brain oedema, vascular spasm, hydrocephalus, CNS disturbances e.g. DI
  • Cardiac – hear failure, stiff heart, pulmonary complications, cerebral complications

Consider post-op checklist

References

Post-operative hypoxia

Transplantation and Immunosuppression (Meyfroidt)

HLA; class 1 on all nucleated cells, class 2 on antigen presenting cells

Immunosuppresant drugs

  • Glucocorticoids
  • Calcineurin-inhibitors; cyclosporine, tacrolimus
  • DNA-synthesis inhibitors; AZT, mycophenolate
  • Antibodies; depleting or non-depleting
  • mTOR inhibitors; sirolimus, everolimus

Rejection

  • Hyperacute rejection
  • Cellular rejection
  • Humoral rejection

Kidney transplant complications

  • Surgical complications; vascular, ureter
  • Delayed graft function – living donor 5%, DBD 30%, DCD 50%

Liver transplant complications

  • Monitor liver function
  • Bleeding
  • Arterial complications: ultrasound – early/late hepatic arterial thrombosis

Heart transplant complications

  • Bleeding
  • Rhythm – denervated
  • RV failure – inotropes, iNO
  • LV dysfunction/failure – inotropes, mechanical assist
  • Renal dysfunction – calcineurin inhibitors

Lung transplant complications

  • Respiratory – protective ventilation, assess structures with bronchoscopy, chest tubes, phrenic nerve injury, ischaemia/reperfusion, difficult weaning (anxious/pain)
  • AF
  • Cystic fibrosis: other manifestation e.g. liver GI
  • Infections

Infections – bacterial, viral, fungal, protozoal

References

Review of immunosuppresant drugs

Critical Care Refresher Course: Abdomen

Acute Liver Failure (Rothen)

Grades of hepatic encephalopathy

  • Grade 1 – Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction
  • Grade 2 – Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour
  • Grade 3 – Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation
  • Grade 4 – Coma

Acute liver failure is a multisystem disorder – hepatic damage leads to endotoxemia –> MODS

Mechanism of drug-induced hepatic damage – idiosyncratic (immune and non-immune) or toxic

Paracetamol may be used in non-paracetamol related liver injuries

Cerebral oedema occurs in up to 75% of pts with grade 4 encephalopathy

  • lactulose and rifaximine in ALF controversial

In absence of bleeding or invasive procedures in unnecessary

Prophylactic antibiotics is controversial

Prognosis is improving although it is highly dependant on the underlying aetiology

 

References

NEJM Review of acute liver failure

Aetiology of acute liver failure

Liver toxins database

Paracetamol toxicity

Management of acute liver injury

Review and King’s criteria for liver failure

 

 

Chronic Liver Diseases and Transplantation (Wendon)

Key to management is the aetiology

CT WITH contrast, US and Echo should be standard investigation in the cirrhotic patient

Organ issues

  • Cardiac – cirrhotic cardiomyopathy, impaired response to stress, diastolic dysfunction, Pulmonary hypertension
  • Renal – true hepatorenal syndrome is rare; the cause is often multifactorial. Creatinine is a very poor marker of renal impairment in liver failure. Treatment – consider terlipressin and albumin
  • CNS – encephalopathy increases ITU stay and mortality. Management – care of airway, no evidence for protein, consider precipitant and treat. MARS device has no
  • Infection
  • Varices – not all pts with varices have cirrhosis. Restrictive Hb strategy. TIPS early
  • Coagulation – pts have balanced coagulation as they also have low ATIII, protein C and S
  • Respiratory – hepatopulmonary syndrome. SHUNT!

Propofol and clonidine sedative of choice in liver failure. Small bolus opioids.

References

Lancet: Review of liver cirrhosis

Hyponatraemia and cirrhosis

Acute vs acute-on-chronic liver failure

Early use of TIPS

CANONIC Study

 

Liver Surgery (Sitzwohl)

Liver resection is increasing; metastases (majority), primary liver tumour, benign lesions

Mortality improving – 2% BUT complication 20-30%

Major complications – SEPSIS, wound infection

Fluids – less is more; CVP has direct effect on blood loss

Coagulation – abnormal lab values DO NOT predict bleeding risk = BALANCED COAGULATION. Aprotinin and transexamic acid is of uncertain value in these patients.

Sedation – NOT Midazolam. Cautious Dexmedetomidine. NOT Morphine. Bravo Remifentanil. Yes Propofol

Modified eFAST scan is useful in liver transplant patients to look for free fluid

 

References

Morbidity and mortality after liver surgery

CVP and liver resection

Renal failure after liver transplants

Probiotics in liver transplant

 

Critical Care Refresher Course: Nervous System

Traumatic Brain Injury (Stocchetti)

GCS has its’ limitations on ICU

In traumatic head injuries, liaise with neurosurgical colleagues early

Repeat CT brain routinely 12-24 hours or sooner if concerns

 

References

Glasgow Coma Scale

ESICM Guide to assessing neurology of patients on ICU

ICP or not?

Prognostication post TBI in CRASH Trial

 

Brain death (Rothen)

The number of people waiting for organ transplant is increasing

Brain death pathophysiology

  • Sympathetics storm
  • Loss vasomotor control
  • Loss respiratory control
  • Endocrine changes; pituitary failure, thyroid failure, hyperglycaemia

Increased ICP -> early compensatory arterial hypertension (Cushing reflex) -> ‘sympathetic storm’ -> loss of vasomotor tone and peripheral vasodilatation

Protocolised care improves the management of organ donors

 

References

www.cobatrice.org

Management of potential organ donor

UK guide for diagnosis of brain death

Organ donor management targets

Protocolised care for organ donor: MONITOR Trial

 

Organ donation (Guttermsen)

Huge discrepancy in demand and organ donation

Types of donors

  • Living donor
  • Heart-beating, brain dead donor (BSD)
  • Non-heart beating donor (DCD)

 

References

European report on organ transplants

Donation after circulatory death

 

Critical Care Refresher Course: Infection and Inflammation

Catheter related infections (Paiva)

CVCBSI is a problem not just inside the ICU but also outside

Risk factors

  • Non-alcoholic antiseptic solution
  • Femoral site
  • Duration of catheterisation
  • Trauma/immunocompromised pt
  • Medical cause of admission

Use a bundle approach for CVCBSI prevention

Clinical findings are unreliable for the diagnosis of CVCBSI; you need blood cultures from CVC and peripherally

Minimum duration of antibiotics for CVCBSI is 14 days

Daptomycin is an alternative for vancomycin with a safer side effect profile

References

Matching Michigan

Bundles for CVC management

Chlorhexidine bath

 

Ventilator-Associated Pneumonia (Martin-Loeches)

VAP accounts for he vast majority of ICU HAP which is associated with increased morbidity and mortality

Risk of VAP highest in the first week of mechanical ventilation

Know your local pathogens and hence the appropriate antibiotic treatment

If you suspected VAP, get the microbiological sample!

References

Latest CDC definitions for VAP

ECDC Guidelines for management of HAP and VAP

 

Fungal Infections in ICU (Eggimann)

Rate of candidaemia is 10 times greater on ICU compared to general hospital patient

Invasive candidiasis may take up to 7-14 days of exposure before developing

40-80% of ICU patients would be colonised by colonised but only 1-10% would develop systemic infection. The challenge is to decide who gets empirical antifungal?

Consider use of Candida Score and discuss with colleagues

References

Prevention of invasive candidaemia

Treatment strategies for candidiasis

Who to start empirical antifungals?

Candida score