Category Archives: LIVES 2016 – MILAN

Clinical Trials in Intensive Care (Monday)

INSTINCT

Intravenous polyspecific immunoglobulin G for patients with necrotizing soft tissue infection: Results of the randomised, blinded, placebo-controlled INSTINCT trial – presentation by Martin Bruun Madsen, Copenhagen, Denmark

This trial looked at all comers with necrotising soft tissue infections and was a blinded RCT using IV IG versus placebo.  They found no difference. Does this mean we should stop giving what is an expensive treatment with no benefit to people with necrotising fascitis? Not sure yet…

Read the paper when you can…

SPICE-PAD

Early pain, agitation, depth of sedation and mobilisation as predictors of 180-day mortality: A multinational prospective longitudinal cohort study (The SPICE-PAD Study).

Speaker: Yahya Shehabi, Sydney, Australia

Interesting observational study that shows that these things do predict mortality.  But this is an association – is more work needed progress this?  It uses the “sedation index”  taking the mean of the sedation part of the RASS scores for a day.

IRONMAN

Intravenous iron or placebo for anaemia in intensive care: The IRONMAN randomised controlled trial

This trial IS available to read here.  Also its PI Ed Litton is on twitter and seems very amenable to interaction! Overall It didn’t show a benefit of infusing Iron.  Enteral iron doesn’t work in ICU pts as hepcidin (the “master regulator”) is generally raised as an acute inflammatory marker and prevents absorption, but previous reports of reaction to Iron infusions have put people off using it – IRONMAN showed it is safe in ICU patients.  But its not an effective way to reduce transfusion, although it may have suffered from being underpowered.

https://twitter.com/ed_litton/status/782963426335268868

Nitric oxide administration during paediatric cardiopulmonary bypass: A randomised controlled trial

Speaker: Warwick Butt, Melbourne, Australia

 

This trial (also published in ICM) looked giving Nitric Oxide to children on bypass – previous data has been encouraging. The rationale is that bypass causes SIRS (from contact activation, ischaemia reperfusion, direct myocardial injury & transfusion) and that NO may help prevent this  – it decreases infarct size in ischaemia reperfusion in rats for example, and recent adult trials have been positive.

The trial found a significant difference and low cardiac output syndrome was halved in group given nitric oxide

HYPRESS

Hydrocortisone for Prevention of Septic Shock (HYPRESS): A randomised controlled trial

Headline from this trial was that Steroids don’t prevent septic shock.  The trial was contemporaneously published in JAMA.

Some good comments after the presentation from Todd Dorman (SCCM president) – The study was probably underpowered (as septic shock was only present in 20% of patients), the finding that in the group who received steroids there was less delirium is “interesting” and recruitment was prolonged – 5 years a long time in ICM and background care probably changed a fair amount over that time.

 

DESIRE

Dexmedetomidine for ventilated septic patients in ICU: A multicentre randomised controlled trial

Speaker: Kyohei Miyamoto, Wakayama, Japan

Interesting study that tried to test the idea that dexmetotomidine is immunonodulatory and therefore useful in sepsis (as a sedation agent).  It made no difference to the outcome (ventilator free days or mortality) but:

 

A fair comment was made that as an open label trial, it carried a high risk of bias which makes the “quality of sedation”  finding more difficult to interpret.

Last but not least…

MACMAN

(McGrath Mac videolaryngoscope versus Macintosh laryngoscope for orotracheal intubation in intensive care patients: The randomised multicentre MACMAN trial)

This neat trial from Jean-Baptiste Lascarrou (available on twitter) looked at a video laryngoscope called McGrath and tried to see if it could increase first pass intubation rates from 65% to 80% compared with direct laryngoscopy with a macintosh blade. In the end it didn’t and both groups had a 70% first pass rate.  The interesting thing was, as you might expect if you regularly use these devices, that the reason for failure was different – In some ways it is a compromise between getting a good view (harder with mac) and getting the tube in (harder with a video laryngoscope in this case McGrath)

 

LIVES 2016: Neuromonitoring in acute brain injury

Interesting session on current and future neuromonitoring in acute brain injury – mainly focused on bedside monitoring but also some imaging

Excellent introductory slide from Giuseppe Citerio about options currently available for monitoring so have bumped it to the top:

img_6482

Also worth looking at – nice review on neurological prognostication after cardiac arrest:

http://www.sciencedirect.com/science/article/pii/S1474442216000156

Automated infrared pupillometry – Mauro Oddo

Infrared video pupillometry: infrafred camera, processor and LED calibrated light source in simple handheld device

Two main options:

Neurolight Algi-scan (ID-MED France)

image1

NPi-200 (Neuroptics, USA)

npi200_100x100_72dpi

Only moderate inter-rater reliability in pupillary assessments using standard clinical approach i.e. torch and subjective assessment: https://www.ncbi.nlm.nih.gov/pubmed/26381281

Good inter-rater reliability for pupillometry. Big difference between standard assessment v pupillometry: https://t.co/MSwD9JG7RI

Quantitative devices also much better at diagnosing pupillary asymmetry (L v R) and therefore highlighting deterioration quicker

In cardiac arrest, during CPR – possible to detect recovery of light reflex with pupillometry. Linked to survival v no reflex: https://www.ncbi.nlm.nih.gov/pubmed/22659054

Awaiting larger cohort study post-arrest – 288 patients included and hoping to present next year at LIVES 2017

Also of potential benefit in acute TBI – predicting uncal herniation: https://www.ncbi.nlm.nih.gov/pubmed/12546375

Non invasive assessment of brain oxygenation – Pierre Bouzat

Firstly NIRS – what exactly are we measuring and how?

Early discussion of limitations. Light scattering by tissues. A fair number of estimations so no actual value for cerebral oxygenation e.g. variation in diffusion path-length factor (DPF) between patients and injuries may affect values .

What anatomical and physiological factors affect NIRS? https://www.ncbi.nlm.nih.gov/pubmed/17325503

  1. Hb
  2. Skull thickness
  3. Area of CSF layer

Caution using NIRS with subdural haemorrahge – may not be able to exclude that you are measuring oxygenation of clot

Extracranial contamination – significantly affect NIRS measurements of cerebral oxygen saturation: https://www.ncbi.nlm.nih.gov/pubmed/22343469

NIRS in subarachnoid haemorrhage: no relationship between absolute rSO2 values and DCI

Tissue oxygen saturation monitoring using MRI – may be a future technique for prognostication: https://www.ncbi.nlm.nih.gov/pubmed/25005878

Question: Could NIRS be more useful as a dynamic variable rather than static number? Overwhelming take home from talk was a lot of concern about use of NIRS outside operating room. Potentially of use post-cardiac arrest and in ECMO

Quantitative EEG: Ready for use by general intensivists? – Giuseppe Citerio

Continuous EEG gives us more information than we had before and as a consequence can potentially do things differently e.g. intervene earlier

Caution though: James Cash Penney – “Theory is splendid but until put into practice, it is valueless”

Options for ICU EEG:

  1. Spot EEG (one occasion)
  2. Continuous EEG
  3. Quantitative EEG

But substantial barriers to adopting routine clinical EEG services on intensive care:

  1. Lack of uniform terminology
  2. No consensus on clinical significance
  3. Infrastructure
  4. Need to simplify complex info so clinicians can quickly ID issues
  5. Personnel – to apply the EEG and interpret results

Important to fully engage neurophysiology services to set up critical care EEG

Also – role of mobile app technology to help adoption on ICU

Potential is huge though

EGDT the end of an era?

This was a very well attended session that began with Richard Beale taking the room through the history of EGDT – Stephen Cains dog studies showed the link between oxygen delivery and consumption, then Schumaker and Shoemaker (there is a difference!) took the concept into humans and then we had Rivers now famous study.  What i found interesting was the paper by in JAMA (http://ja.ma/2dm4K0e) from surgical patients in the early 90s which really re-ignited the idea of goals and targets, albeit in the more controlled post-op surgical insult population, but this was a key driver for Mani Rivers protocol in his study.

Then Derek Angus gave his presentation which is also going to be available (along with my interview with him afterwards) on the ESICM website to watch.

Then Andrew Rhodes talked about the future and gave some common sense advice on how to treat sepsis.  The room was full – so as JLV said today, that means we still have a problem in how to treat sepsis! Will top the bill at conferences for some time to come yet…

 

Central Venous Catheters in the ICU

US-guided CV cannulation (Saugel)

Preventing Complications of Central Venous Catheterization — NEJM http://www.nejm.org/doi/full/10.1056/NEJMra011883#.V_OduHslmqI.twitter

Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization:
http://www.cochrane.org/CD006962/ANAESTH_ultrasound-guidance-versus-anatomical-landmarks-for-internal-jugular-vein-catheterization

Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization: http://www.cochrane.org/CD011447/ANAESTH_ultrasound-guidance-versus-anatomical-landmarks-for-subclavian-or-femoral-vein-catheterization

Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists: https://www.ncbi.nlm.nih.gov/pubmed/27491563

Practice of ultrasound-guided central venous catheter technique by the French intensivists: a survey from the BoReal study group: https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-016-0177-x

 

CVP measurement issues (Magder)

CVP can be thought as “preload” or as “outflow pressure”

CVP does not tell you blood volume

CVP does not allow you to reliably predict fluid responsiveness

Measurement is zeroed at the level of the stopclock

The value is taken at the bottom of the ‘a’ wave at end expiration

 

CVP intepretation issues (De Backer)

 

Can ScvO2 replace ScO2 (Scheeren)

SvO2 to monitor resuscitation of septic patients: let’s just understand the basic physiology – https://ccforum.biomedcentral.com/articles/10.1186/cc10491

Measurement of central venous saturations can be measured continuously or intermittently

Mixed- vs Central- venous saturations are comparable, normal central lower by 2-3% in health

Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock: http://icmjournal.esicm.org/Journals/abstract.html?doi=10.1007/s00134-006-0270-y

Can femoral saturation SfO2 replace ScvO2?

pCO2 gap – how to use (Teboul)

review: http://lifeinthefastlane.com/ccc/pco2-gap/

Vallet B, Pinsky MR, Cecconi M. Resuscitation of patients with septic shock: please “mind the gap”! – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3732761/

Vallet B, Teboul JL, Cain S, Curtis S. Venoarterial CO2 difference during regional ischemic or hypoxic hypoxia. J Appl Physiol. 2000;89:1317–1321.  PubMed PMID: 11007564

Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O2 content difference ratio as markers of resuscitation in patients with septic shock https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414929/