Category Archives: LIVES 2016 – MILAN

A challenges for the next generation of European ICM trainees: EDEC

Proving your proficiency in your chosen field has long been tested by the sitting of postgraduate exams such as the EDIC, but beyond this there are proofs of practical proficiencies combined with the knowledge of how to use them—presenting the European Diploma of EchoCardiography.

EDEC: How do I become ICU-Echocardiography proficient?

Nick Fletcher, London

It all stems from this document. Although we have know for quite a while that it is certainly a good idea and complements, and adds to immediate clinical practice for clinical practice.

We have a different skill set to cardiologists and look at different things, so it make sense to learn in a slightly different way.

There are good examples of intesive care doctors finding things on echo that the cardiologists may have not spotted. Let’s get as many people as possible this skill. But it’s not for everyone as EDEC is pitched at quite an advanced level. Training in the echo required for cardiac anaesthesia isn’t pitched right for critical care echocardiography.

So, what can you expect?

You’re going to need to do some basic echocardiographic training. Take your pick of proficiency. Then the EDEC training begins, with an ESICM-endorsed training programme.

That’s 40 hours of training, of which the ESICM advanced echo course is the only mandatory component. Then there are webinar programmes currently in development. There are going to be an increasing number of locally-delivered EDEC-endorsed courses.

You are going to need a mentor & supervisor to guide you through. Your mentor doesn’t necessarily have the full range of critical care echo skills, but can provide cognitive or technical skills to get you through. They can be an echo tech, an intensivist or cardiac anaesthetist.

A supervisor is suitably qualified to train and fully supervise. They should have a national or international qualification with expertise in TTE or TEE(TOE) (in the UK this might be BSE or ACTACC, formerly ACTA). They can apply to become an EDEC supervisor. They may not be in your centre. They might also be able to help you reach other centres to gain expertise and complete your logbook.

The logbook requires 100 TTE scans and 35 TEE(TOE) scans. No more than 20 / 7 respectively should be normal scans or repeated in the same patient or have significant technical limitations. The EDEC report must be used and uploaded to the online logbook repository.

And then there’s the exam

You need to be eligible for it (work in critical care). You need to have an approved mentor and supervisor (registered with EDEC). You’ll need the advanced course under your belt and 40 hours of training. The logbook doesn’t need to have been completed by then, but you’ll need to be making good progress towards it (60 cases at least uploaded to the logbook).

The exam has 3 parts:

50 MCQs,  without images, asking about physics, quantification and haemo-dynamics

10 case reporting images follow

If these are both passed, then you are invited to have a face to face TEE(TOE) OSCE on a simulation mannequin.

The whole process is envisaged to take 2 years. And you are likely to be at least 1000€ poorer, but if you pass you are more than better off!

If you need any more information, then head over to http://www.esicm.org/education/edec for everything you need to know.

Get going now and you could be the first person to be awarded the EDEC. Race you!

Peri-operative Right Ventricular Failure

A problem that can clearly be served up to us all. But we’re more familiar with LV failure. So what shod we do? Read on…

Sascha Treskatch

  • The incidence is low (thankfully)
  • Predispositions
    • Cardiopulmonary bypass
    • Pulmonary hypertension
    • RV functional reduction
    • Hypervolaemia (!)
  • Consider what the RV function is like when assessing if the LV is going to be fluid responsive. Article here.
  • Guidelines recommend using echo. assessment first before more invasive measure used (of course)
  • 2 good articles telling us lots about the RV , and what gets done by us to worsen its function I and II
  • A nice little algorithm presented for management

Summary management

  • Adequate preload
  • Maintain a good MAP to ensure (right) coronary perfusion
  • Support contractility
  • Reduce PVR (PDE II inhibitors)
  • Transfer out (potentially for extracorporeal support)
  • Another little algorithm about what exactly to do (non-echo-based)

 

Some food for thought, and some guidance to think about at least. I think I will have a better idea of what to do, perhaps in what order now, and definitely think more about the RV/LV interactions.

Antibiotic stewardship in ICU

An important topic as antibiotic resistance is a growing problem across the world.

Dr Escoresa-Ortega presented her study looking at antibiotic de-escalation, and showed that antibiotics are often not de-escalated when they should be (about 70% of the time).  She identified risk factors for “no de-escalation” as a high SOFA score, previous antibiotic use, and abdominal or respiratory source of infection.  An interesting point made during the session is why exactly we dont de-escalate, and this study helps point to patient factors – but maybe there are more physician factors at play.

Next an interesting paper trying to think about what we ought to do with patients on antibiotics and renal replacement therapy.  The paper presented by Dr Muller looked at drug levels in 16 patients and showed the “best” strategy for amikacin was to use extended high dose therapy (25 mg/kg 48-hourly).  Again an interesting discussion ensued.  In general the principles of using antibiotics when on renal replacement are

  1. Start with a high dose first and then back off
  2. Use continuous (not intermittent) methods of renal replacement
  3. Use CVVHDF preferentially
  4. Interestingly continue RRT for 48hrs – should this be even in the face of no OTHER clinical indication? Im not sure, but if high dose has been given it could be a risk to stop.
  5. Drug monitoring – some in the room are great advocates for this, but it is a scarce resource in most ICU environments.  Apart from for amoniglycosides and glycopeptides routine access to therapeutic drug monitoring is rare (at least in a show of hands in the lecture here…)

Then we discussed Linezolid – a paper presented by Dr Munoz-Bermudez showed that only about a quarter of patients were in range when treated with the drug for gram positive infection at a dose of 600mg BD (most were subtherapueetic).  Renal failure seemed to be associated with both over and under treatment.  This is an odd but interesting finding if one considers that the manufacturers do not recommend drug dose alteration in linezolid treatment, but illustrates the problem with using these drugs in the ICU – many of the antibiotics are licensed following trials that dont have lots of critically ill patients.  Another plug for drug monitoring from the enthusiasts and they have a point.

Finally we heard about the Spanish zero resistance programme – an attempt to deal with the problem of antibiotic resistance via various measures.  One of these is use of a checklist – and Dr  Carvalho Brugger did a neat study looking at using a checklist.  It didn’t perform particularly well, missing several patients with resistant bugs – it only picked up 36% of them. Better than nothing? Or another form to get in the way…

The chair of the session Jeffrey Lipman finished with a caution; taking too many lessons on dealing with antibiotic resistance from one country to another might not work – we need to adapt to our own unit/region/country.

Functional Haemodynamics to Improve Functional Outcomes

What is functional haemodynamics? (Pinsky)

Qns to ask when assssing pts:

Precise Personalised Resuscitation is the KEY because a monitoring device by itself will not improve pt outcome without being coupled to a treatment algorithm.

  • Is pt haemodynamically stable?
  • Is pt pre-load responsive?
  • Is pt hypotensive and have reduced vasomotor tone?

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