Category Archives: LIVES 2015 – BERLIN

Intra-arrest Care

How to optimise CPR

No benefit to CPR > 60mm depth. However, although pauses are associated with worse outcomes it might not be that it’s because it increases likelihood of terminating CPR.

ETCO2 is increasingly important and improvements in ETCO2 have been seen with increasing depth of CPR but not rate.

Best option:

  • Rate 100-120
  • Depth 5-6 cm
  • Minimise interruptions
  • Use physiologically directed CPR (ETCO2 or blood pressure?) where possible

Peri-shock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest

Association Between Chest Compression Interruptions and Clinical Outcomes of Ventricular Fibrillation Out-of-Hospital Cardiac Arrest

Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis

 

Drugs During CPR

Adrenaline

  • Evidence based on animal experiments
  • Beta affects are detrimental
  • Reduces cerebral microcirculation!
  • Associated with improved short term but worsened long term outcomes

Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial

A randomised placebo controlled trial of adrenaline in cardiac arrest—The PACA trial

Vasopressin no better than adrenaline

Amiodarone improved ROSC but no survival benefit

However, OOHCA is different to IHCA and Greek trial suggested favourable neurological outcome with adren/vaso/steroids

Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest

Bad quality CPR won’t be saved by drugs

No benefit from high-dose (i.e. > 1mg) adrenaline

 

Cerebral Oximetry during and after CA

Cerebral oximeters use a variety of different arrangements of lights and detectors and assume a fixed ratio of arterial and venous blood, normally 25-30:70-75. Balance O2 delivery and uptake in real time. Normal range 60-75% and used more extensively in neurosurgical and cardiothoracic surgical settings.

Trends are probably more useful than individual values; however, really high initial values might be worth pursuing longer? Data limited. There is evidence that people with higher cerebral oxygenation values do better but overlap is significant between group and lacks specificity.

Increase in cerebral oxygenation during advanced life support in out-of-hospital patients is associated with return of spontaneous circulation

Cerebral oximetry and return of spontaneous circulation after cardiac arrest: A systematic review and meta-analysis

Cerebral Oximetry as a Real‐Time Monitoring Tool to Assess Quality of In‐Hospital Cardiopulmonary Resuscitation and Post Cardiac Arrest Care

 

Identifying the cause of CA during CPR

Most CA are due to cardiac causes and account for 20-30% of all deaths. Most of this is IHD.

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Hypoxia should be treated empirically. Hypovolaemia may be more difficult to diagnose if concealed, e.g. AAA, GI, spleen. Otherwise, follow the guidelines and get what you can from the history +/- ancillary tests such as echo.

The spectrum of epidemiology underlying sudden cardiac death

Clinical Trial Session 2

CAESAR Study (Azoulay)

Post-ICU syndrome and the burden of care on relatives. Hence the need to develop a tool to assess this.

A high CAESAR score represents higher family satisfaction with care

Conclusion – CAESAR instrument

  • new instrument based on family experience that will help develop family centred care
  • lower scores associated with higher burden
  • clinically, may be useful to identify vulnerable families

 

FLUID-TRIPS (Hammond)

Albumin studies – SAFE, VISEP, CRYSTMAS, CHEST, 6S, ALBIOS

Inter-country variation in types of fluid prescribed

Conclusion

  • signification variation in fluid use remains
  • significant secular changes in patterns of fluid resuscitation between 2007-2014
  • crytalloids still predominate
  • increased use of balanced salt solutions
  • pattern of colloid use consistent with recent RCT

SAFE TRIP study

Fluid-TRIPS protocol

 

CHECKLIST-ICU (Cavalanti)

Checklist and daily goals read out during round

No difference in mortality!

CHECKLIST ICU Trial protocol

Trial statistical analysis plan

Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

 

Very high volume hemofiltration with the Cascade system in septic shock patients

Cascade trial

 

 

How to feed the critically ill – Dr James Day

Why is hypocaloric feeding better- Casear

Doesn’t kill nor saves lives

May avoid infections and enhance recovery

Doesn’t compromise recovery

Reduction of ICU acquired weakness

Early nutrient restriction and hypocalorific feeding are harmless and may enhance recovery

Early nutrient restriction avoids early suppression of autophagy in skeletal muscle

The optimal duration of nutrient restriction and role of different macro nutrients needs to be further eleucidated

Should autophagy be respected or activated?

 

References

EPaNIC Study

Review: Timing of PN

CALORIES trial

 

Feeding and Chronically Critically ill-Guttormsem

What does chronically critically ill mean:

  • Presence of tracheostomy
  • On ICU>7 days

Unresolved issues:

  • How much energy to give?
  • Hypocaloric or isocalorific- different targets in different phases of the ICU/hospital stay

How much protein to give- need to see energy, protein and muscle as unity.

Is it possible to identify the critically ill patient at nutritional deficiency?

Energy demands may double in the rehabilitation phase of critical illness. They are back on the ward then.

When pt out of bed (i.e. rehabilitation phase) feed to put on weight (muscle mass)

 

References:

The evolution of nutrition in critical care: how much, how soon?

 

Let’s talk about Post Intensive Care Unit Syndrome – Hannah Wunsch (presented 4th October)

In this presentation, Dr Wuncsh highlights some important key points:-

There are some significant negative consequences for our patients after discharge from the ICU.  Not only is QOL decreased for at least two years after hospital discharge, but patients can also suffer psychological and physical consequences such as anxiety and mood disorders, extreme fatigue, sleep disturbance, weakness, foot drip and more.

Some general tips for improving the patient experience and decreasing the impact of PICS include:-

  • Minimising sedation
  • Tailoring the environment to reduce noise and night disturbance
  • Early physical and cognitive therapy
  • Screening for psychiatric disease
  • ICU diaries

By

Dr Melissa Bloomer