Category Archives: Year in Review

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France

Hot Topics Session

It is well recognised that critically ill elderly patient have a higher mortality and therefore the beneficial effect of intensive care unit (ICU) admission variable ICU use among this population have let to significant difference in uptake.

Guidet and colleagues performed a cluster, randomised trial of admission versus standard care in 3036 elderly patients aged 75 years and above. In their multicentre randomised trail, suitable patients were allocated to routine or non-routine admission as per the following:

CONSORT Diagram

Outcome Measures

  • Primarily 6 months
  • Secondarily ICU admission rate, in-hospital death, functional status and quality of life.

 

Results

Results

 

  • Disappointingly there was no difference seen in any of the outcome measures, even after adjustment for differences in illness severity and patients admitted to ICU had an INCREASED risk of death at six months despite an increase ICU admission rates.
  • Functional status and physical quality of life at six months did not differ significantly.

 

What does this mean?

  • As our ICU population changes it may be that a systematic approach which admits all elderly patients has no effect upon outcome.
  • Further international trials are needed before we know whether this is applicable to other populations.

ICM year in review: respiratory, cardiodynamics and renal

This first session of the day in room Lisbon was a rapid run through of the journals’ most important papers of the last year  – a bumper year as the journals impact factor has soared.

Some notes below:

Respiratory papers

IC-GLOSSARI, the Intensive Care Global Study on Severe Acute Respiratory Infection which was a great ESICM project led by Yasser Sakr and is described as “a multicenter, multinational, 14-day inception cohort study”, in which I admit a COI in that i was involved on one of the sites, but a good paper in that it crossed continents and showed that admission to the ICU for severe lung infection is not only common but also associated with high morbidity and mortality rates.

http://link.springer.com/article/10.1007%2Fs00134-015-4206-2

ECMO epidemiology, this German study showed an increase in ECMO use especially amongst more elderly patients, since 2007.  VV ECMO seems to have reached a “plateau” in use. Mortality has decreased over time – the authors attribute this to experience – but is still stunningly high –  58 and 66 % for vv-ECMO and va-ECMO respectively.

http://link.springer.com/article/10.1007%2Fs00134-016-4273-z

ARDS rehabilitation – Pfoh and colleagues examined “physical declines occurring after hospital discharge” in people who survive ARDS and followed up patients for 5 years.  The headline is that most people decline, and older people and those with co-morbidities decline more.

http://link.springer.com/article/10.1007%2Fs00134-016-4530-1

Lung US training – This paper followed 11 respiratory therapists who had never used ultrasound before over 9 months and claims that 12 scans is the magic number to attain competence.  The jury is out…

http://link.springer.com/article/10.1007%2Fs00134-015-4102-9

The TRACHUS trial looked at ultrasound for tracheostomy – a good idea surely.  Anyway the paper says that it is safe and useful.  As @PhilMcglone said in his review for The Bottom Line – Why choose between bronchoscopy and ultrasound when we can use both?

http://link.springer.com/article/10.1007%2Fs00134-016-4218-6

Finally in the respiratory section this directions-type paper from Jeremy Beitler and the ARDSnet group (now ARDSne(x)t – see what they did there…) on personalising ARDS treatment. The research agenda is going to ask simultaneously both “whether a treatment affords clinically meaningful benefit and for whom.” Watch this space. Or read the paper:

http://link.springer.com/article/10.1007%2Fs00134-016-4331-6

Cardiodynamics and Ultrasound

Antoine Vieillard-Baron discussed the most important papers from this excitingly titled topic.

The FENICE trial was another landmark “global inception cohort study” and looked at fluid management and fluid boluses ( et al).  It showed massive variation in what a fluid bolus is and how it is used.  The question posed by AVL was why did only 2% of physicians use echo to manage fluid? Not enough trainers? Too difficult? Maurizio himself weighed in on the twitter chat below:

Then a study from 3 countries on point of care ultrasound use was presented.  Adrian has reviewed it nicely here for the NEXT journal club – or read the paper.  POCUS is underused generally, and only half the CVC insertions were performed under US guidance.

http://link.springer.com/article/10.1007%2Fs00134-015-3952-5

Finally a nice review article (authored by the presenter) on how to use ultrasound in ventilation management – 4 key areas:

  1. Assessment of cardiac function
  2. Assessment of diaphragmatic function
  3. Assessment of lung function
  4. Identification of pleural effusion

http://link.springer.com/article/10.1007%2Fs00134-016-4245-3

Kidneys

Matt wrote a nice blog on this yesterday, so briefly some of the papers discussed today were:

Statins in heart valve surgery

http://link.springer.com/article/10.1007%2Fs00134-016-4358-8

The kidney injury epidemiology study (AKI-EPI)

http://link.springer.com/article/10.1007%2Fs00134-015-3934-7

And the Truche study – looking again at continuous vs intermittent RRT:

http://link.springer.com/article/10.1007%2Fs00134-016-4404-6

LIVES 2016: Opening Presentations

Daniel De Backer – President ESICM

What has happened in 2016?

7 key points

  1. Members: 8550 now (continuous increase)
  2. NEXT committee: 115 fellowships since 2014 – trainees and young specialists from across Europe. New Pain/Agitation/Delerium (PAD) and Bayer Fellowships rolling out. ICE-mentoring – 28 mentors/58 mentees
  3. Education: academy and interactive e-learning. EDIC preparation course with mock exam. New courses. New courses e.g. Mechanical ventilation + EDIC 1 and 2 preparation courses. EDEC (Extending knowledge of the diagnosis of cardiac dysfunction and advanced use of echo) – new diploma. 64 intensivists enrolled. Webinars e.g new sepsis definitions, LUNG SAFE study
  4. Research: Increasing investment in research~ €600,000. ESICM Trials Group – 10 studies and 20K patients. JAMA/ICM Journal publications. Protocol Library
  5. Journal: ICM – highest impact factor yet ~ 10.125 currently. Monthly webinars and ICM Pulse related to most relevant publications. ICMx – experimental research
  6.  Communications: Social Media, Blog
  7. Coming soon: EuroAsia 6-8 April 2017. ESICM eBook series on Lessons in ICU. Surviving Sepsis Campaign – revision of SSC Guidelines 2016 coming soon. Paediatrics SSC, Sepsis in resource limited countries.

A new physiology: Caring for the extraterrestrial (Michael Barratt)

Space medicine meets intensive care

  • Three training programs in US for space medicine – board certified
  • On cusp of commercial space flight so ?expanding
  • Informs overall knowledge base of physiology
  • Accelerates avenues of medical and tech development e.g. USS
  • Thriving international community – work closely together

Radiation – by far the biggest limitation of human space travel

International space station the main destination – much roomier than one would imagine!

Basically a functioning laboratory with centrifuge, freezer, gas analyser (VO2 max etc), EEG, animal research etc

Most common issue needing adaptation is WEIGHTLESSNESS

Most changes adaptive and not harmful but can become maladaptive on return to earth

Seconds to minutes to occur:

  • Anthropometry – neutral body posture
  • Fluid shift – headward direction. Expect CVP to increase. PAC inserted in space – decreases!
  • Neurosensory adaptation  – proprioception altered. Tremendous conflict neurovestibular and occular systems. Sensory conflict but adapt in days

Lung: evening out of V/Q distribution (though incomplete)

VT decreases, RR increases —> net decrease of 7% in ventilation overall. DLCO increases

SUBACUTE (first 10 days)

  1. Fluid regulation
  2. Blood volume
  3. Neurosensory adaptation

ACUTE (3 weeks)

20% decrease in MVO2. CO normal/contractility normal

Bone loss – starts immediately but takes while to take effect. Muscle loss too

Neuro issues too: increased ICP (likely but hard to test in space…), ophthalmic disc oedema, choroidal folds —-> USS: x2 increase in optic sheath diameter. But unsure why?

ESICM Society Medal – Rui Moreno

Extremely well deserved – huge contribution to ICM – both clinically and through research

Terror victims in the ICU (Serge Jennes)

Description of the ICU and burns management of the Brussels terror attacks this year

Hospital built as disaster hospital – entrance corridor has drop down panels with O2 and suction

Incredible response – hard hearing about paediatric admissions with severe burns. And families who lost parents – just tragic

1/3 of patients from outside of Belgium – families needing to be reunited in hospital so transfers arranged

18 admissions overall – 6 years to 49 years

9 surgical procedures

120 radiological investigations

20 dressing changes a day for 15 days

Key message: computers are not fast enough. Use paper. Whiteboard for movement of pts

Additional workload: VIP visits (King and Queen of Belgium), insurance company, arrange transfers

Plus – dont forget hospital becomes target itself. Security issues

Take home messages:

  1. Be prepared: know your enemies and treat first what kills first
  2. Rebuild: practice drills, training, improve protocols
  3. Apply and practice protocols learned from recent conflicts in the prehospital and ICU settings

ICM Year in Review 2

Statements and guidelines in ICM (Monza)

10 things to consider before you believe a clinical guideline

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

Strategies to reduce curative antibiotic therapy in intensive care units (adult and paediatric).

Prognostification in comatose patients post cardiac arrestConsensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

Link to primary references

 

Perioperative critical care (Talmor)

230 million surgical procedures worldwide

Unlike other areas, we can influence the patient’s condition before procedure

 

References

More perioperative care research and work

Extubation onto high-flow nasal cannula

Prophylactic NIV in COPD patients post-op

EUSOS study

 

ICU Organisation (Soares)

Regional variation in critical care provision UK

Association between ICU level of care and mortality in Netherlands

ICU by size and level

After hours discharge

Do you know how much ICU care costs?

Editorial on cost of ICU

Quality improvement programme on weaning from mechanical ventilation

 

The three best 2014 papers in ICM (Azoulay)

De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock

Prophylactic NIV in COPD patients post-op

Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study.