Category Archives: Circulation

Jerry Nolan talks cardiac arrest resuscitation at #LIVES2020

Watch the interview in the VOD section but here is a tweetorial summarising the discussion. I’ve included the key references…

Session: How to evaluate body composition in fluid-resuscitated patients

Bioimpedance can make it

Julius Grunow  (Berlin, Germany)

 

BMI does not reflect body composition

Obesity paradox: Decreased mortality in overweight and obese patients contrary to decreased survival in general population (excluding the underweight and morbidly obese) – ? related to greater nutritional reserve

Low skeletal muscle mass is a risk factor for mortality in mechanically ventilated pts – as measured on CT (practical limitations for ICU pts)

Bioimpedance analysis (BIA) – bedside tool, radiation-free, reflects physician estimated hydrations levels quite well in prospective clinician-blinded study

Muscle mass at L3 level on a CT is highly reflective of whole body muscle mass. Assessing muscle mass from equations using BIA values vs. CT – Talluri and Janssen equations overestimate / Kyle equation underestimates

BIA cannot accurately / directly calculate muscle mass, however the values CORRELATE well – the consistency in this ‘relative inaccuracy’ may be useful

Phase angle (PhA) correlates well with muscle density = a good marker for muscle quality

==========

Bioimpedance should certainly not be used

Sandra Stapel (Amsterdam, The Netherlands)

 

Body composition analysis can identify pts with nutrition risk, limited physiological reserve and predict adverse outcome (in low muscle mass)

Estimation of different body compartments using Population-specific predictive equations (combination of electrical and anthropomorphic data)

  1. Not valid in critical illness
  2. Accuracy depends on two prerequisites
  • accurate body weight (rarely available in ICU pts – often guess/estimate)
  • normal fluid distribution (almost always abnormal in inflammation and after fluid resuscitation)

Within 1st week ICU admission, phase angle (PhA) and reactance (Xc) both decrease as hydration increases

Potential applicability of BIA in ICU if

1) use weight / height-independent parameters e.g. PhA

2) measuring early in admission  (PhA on Day 1 predictive of 28-d mortality in critical illness and several other pt groups; PhA on Day 5 no longer predictive, likely due to fluid resuscitation)

Low PhA associated with 90-d mortality

Further research should focus on methods to correct BIA equations for fluid imbalance and effects of nutrition / exercise on PhA.

==========

Phase angle to predict ICU outcome

Mette Berger (Lausanne, Switzerland)

 

Lean body mass determines outcome; fat – energy reserves, muscle – defence

Increased pectoralis muscle area on CT – significant increase in 6-mth survival, decreased hospital mortality, more ICU-free days

Measuring LBM:

  • DEXA – not practical
  • CT – at L3 (well-validated) – not practical, radiation
  • MRI – not feasible in ICU
  • US thigh – operator variability, training required
  • BIA – precise values, portable, quick and easy to perform

Main determinants of PhA

  • In health: age, gender, BMI
  • In disease states: malnutrition (Pre-albumin, subjective global assessment), inflammation (CRP, IL-6), fluid accumulation

Lower PhA in pts with advanced cancer undergoing palliative follow-up –> worse overall survival 

Lower PhA on admission in pts who later died during ICU stay (PhA in combination with APACHE II / SAPS II scores provide multi-variable composite score for 28-d mortality)

PhA improves in pts receiving beta-hydroxy-beta-methylbutyrate (metabolite of leucine) vs placebo

 


Critical illness: Increased muscle catabolism and lung production of glutamine

  • whole body production of essential and branched-chain amino acids almost doubles
  • ICU pts low / high SOFA scores – increased glutamine production but decreased plasma [glutamine]

Pts with higher SOFA scores have significantly lower PhA

Currently ICU severity scores not specific for metabolic state

  • PhA provides additional info reflecting cell viability and possibly protein metabolism (as seen in glutamine study)
  • Pick pts who will benefit from nutritional support

 

*Phase Angle = Superior prognostic marker + most precise screening tool for impaired nutritional and functional status currently available*

Myth Busters! #LIVES2020

https://lives2020.e-lives.org/session/myth-buster-facing-myths

5 False beliefs in acute and chronic respiratory failure

Pr Alexandre DEMOULE

  1. ARDS pts should be intubated promptly
  2. Intubation can be safely delayed in ARDS patients
  3. In COPD, NIV is contra-inducated in case of coma
  4. In cancer pts, do everything not to intubate
  5. Response to prone position predicts the outcome

ARDS pts should be intubated promptly

Time to intubation has no impact on mortality

In COPD, NIV is contrainidcated in case of coma

  • NOT AT ALL, in cases of hypercapnic coma, do a NIV trial

In cancer pts, do everything not to intubate

Response to PRONE position predicts the outcome

When lactate is normal the circulation is adequate

Prof J Bakker

The ten pitfalls of lactate clearance in sepsis

Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock
The ANDROMEDA-SHOCK Randomized Clinical Trial

Conclusions

  • The clinical context we create from an increased lactate is: tissue hypoperfusion/hypoxia
    • This is on a macrocirculatory level
  • Lactate levels frequently remain abnormal during the first 24h of admission in survivors of septic shock
  • Mildly elevated lactate levels are associated with increases in mortality and abnormal microcirculation
  • Lactate levels need context
    • Markers of peripheral/microcirculatory perfusion
  • Lactate levels do not denote a state of perfusion

Adrenaline improves outcome after cardiac arrest?

Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Conclusion

  • Survival to hospital admission x 3 higher
  • More survivors to discharge
  • More neurologically favourable survivors
  • More brain-injured survivors

 

False beliefs about duration of antibiotic therapy

J De Weale (twitter)

The FALSE beliefs

  1. Antibiotic duration needs to be ‘fixed’
    • No Biological rationale
    • Bacteria don’t calculate the days exposed
  2. Short courses are less effective
    • Longer courses do not protect against complications
    • BUT some infections do require longer treatment
  3. I need a biomarker to determine duration
  4. Antibiotics need to be continued until clinical symptoms have subsided
  5. An antimicrobial course should always be completed.

Summary

  • Inappropriate antimicrobial use in the ICU is unacceptably high
  • Duration important contributor
  • Management often based on incorrect assumptions
  • “7-days course” current dogma for most infections
  • Individualized therapy is the future
  • AI to refine therapy duration

Prof’s De Weale’s slideset (I like the design)

Prognostication of individual survival chances is not possible? Machine learning is the answer

Prof Mihaela van der Schaar (twitter) www.vanderschaar-lab.com

Machine learning can enable:

1) Delivering precision medicine at the patient level
2) Understanding the basis and trajectories of health and disease
3) Informing and improving clinical pathways, better utilize resources, and reduce costs
4) Transforming population health and public health policy

False beliefs in the management of fever

F Schortgen

Fever is not hyperthermia

Treating fever has never been proven to improve patient comfort

Effect of Shivering on Brain Tissue Oxygenation During Induced Normothermia in Patients With Severe Brain Injury

Antipyresis is NOT necessarily good for haemodynamic stabilistation and tissue oxygenation

 

Temperature management post cardiac arrest #LIVES2020

. @JBLascarrou talks about the various devices that can be used to cool – intravascular, surface or intranasal. #LIVES2020

Previous trials used a variety of different methods #LIVES2020

 

 

Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest: A Randomized, Controlled Study #LIVES2020

https://pubmed.ncbi.nlm.nih.gov/26092673/

Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest – an analysis of the TTM trial data #LIVES2020

https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1552-6

 

The future of cooling? #LIVES2020

 

Ultrafast Hypothermia Selectively Mitigates the Early Humoral Response After Cardiac Arrest #LIVES2020

https://pubmed.ncbi.nlm.nih.gov/33198571/

In conclusion #LIVES2020

 

 

 

TTM – does the duration and timing make a difference? #LIVES2020

Unsurprisingly, cardiac arrest, is complicated and heterogenous #LIVES2020

 

Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest – a landmark #LIVES2020

https://www.nejm.org/doi/full/10.1056/nejmoa1310519

 

 

The efficacy and safety of pre-hospital cooling after out-of-hospital cardiac arrest: a systematic review and meta-analysis #LIVES2020

https://www.semanticscholar.org/paper/The-efficacy-and-safety-of-pre-hospital-cooling-a-Lindsay-Buell/76cb5220affe71abe55db4c7807e14625d349eea

A low body temperature on arrival at hospital following out-of-hospital-cardiac-arrest is associated with increased mortality in the TTM-study #LIVES2020

https://pubmed.ncbi.nlm.nih.gov/27565034/

Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE Trial (Rapid Infusion of Cold Normal Saline) #LIVES2020

https://pubmed.ncbi.nlm.nih.gov/27562972/

 

Timing and duration are crucial #LIVES2020

Ten big mistakes in intensive care medicine #LIVES2020

https://pubmed.ncbi.nlm.nih.gov/25502093/