Category Archives: EuroAsia 2018

From theory to practice – ARDS: An old syndrome, new organ interactions #EuAsia18

Circulation, EuroAsia 2018, Neurology, Renal

The lung and the kidneys (Ostermann)

When kidney function lost, –> reduced clearance , fluid overload, acidosis BUT also inflammation, cytokine release and cell death

The distant organ effects of acute kidney injury

AKI causes a higher degree of capillary leakage within the lungs

Ventilator induced kidney injury

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Bench-to-bedside review: Ventilation-induced renal injury through systemic mediator release – just theory or a causal relationship?
Mechanical ventilation as a mediator of multisystem organ failure in acute respiratory distress syndrome.

Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome

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Lung brain interactions (Oddo)

ARDS in the brain-injured patient: what’s different?

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Issues to consider

  • Oxygenation
  • PEEP
  • CO2/TV

Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update
Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure.

Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates.
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Heart lung interactions (Cecconi)

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Is tidal volume challenge the new PLR? Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation

Or end-expiratory hold?
Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients.

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Strategies in antibiotic therapy #EuAsia18

EuroAsia 2018, Infection

Nebulised antibiotics (J Oto)

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Choice of antibiotics for nebulisation

  • not all antibiotics can be nebulised
  • produce high local concentrations with rapid clearance (poor systematic exposure)

Efficiency of abx nebulisation

  • Particle size
  • Nebuliser type
  • Nebuliser position
  • Circuit humidification management
  • Ventilator settings to avoid turbulence

Nebulization of Antiinfective Agents in Invasively Mechanically Ventilated Adults: A Systematic Review and Meta-analysis.

Nebulized Versus IV Amikacin as Adjunctive Antibiotic for Hospital and Ventilator-Acquired Pneumonia Postcardiac Surgeries: A Randomized Controlled Trial.

Conclusion

  • Nebulised abx provides high lung concentration
  • VAP caused by resistant gram negatives may be efficiently treated by nebulised abx without nephrotoxicity
  • Optimisation of nebulisation techniques and procedures needed

 

Optimising Beta Lactam Therapy (A Wong)

PowerPoint Slides

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Continuous versus Intermittent β-Lactam Infusion in Severe Sepsis. A Meta-analysis of Individual Patient Data from Randomized Trials.

Continuous Infusion Versus Intermittent Bolus of Beta-Lactams in Critically Ill Patients with Respiratory Infections: A Systematic Review and Meta-analysis.

Continuous infusion of β-lactam antibiotics for all critically ill patients?

Prolonged infusion piperacillin-tazobactam decreases mortality and improves outcomes in severely ill patients: Results of a systematic review and meta-analysis

An international, multicentre survey of β-lactam antibiotic therapeutic drug monitoring practice in intensive care units.

Using Old Antibiotics in 2018 (J De Waele)

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Challenges of old antibiotics

  • Lack of clinical evidence
    • Research in that era different
    • No guidance on RCTs
    • No combination therapy
    • Now used for other indications
  • Availability lacking due to manufacturing and logistical issues
  • Dosing
    • Data based on obsolete data
  • Susceptibility data
    • Lacking for many
    • Not standardised
    • Potential for resistance

 

 

#EuAsia18 Keynote: Caring for the Injured Brain

EuroAsia 2018, Neurology, Trauma

Mauro Oddo

Championing individualised neurointensive care

  • Neurological examination
  • Imaging
  • Monitoring

The RCTs of therapies in Neuro ICU have shown no effect on pt prognosis

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EUROTHERM Study

A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury

So what do you do??

Evidence for Health Decision Making — Beyond Randomized, Controlled Trials

Severe traumatic brain injury: targeted management in the intensive care unit.

Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations.

 

But it may be that we are not finding the solution/therapy due to the heterogeneity of TBI

Diverse effects of hypothermia therapy in patients with severe traumatic brain injury based on the computed tomography classification of the traumatic coma data bank.

A response to the Chestnut trial –

A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol.

 

There is therefore an unsurprising degree of variation in how TBIs are managed.

Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study.

  • Outcome was more favourable in pts treated in aggressive centres

 

Multi Modal Monitoring (MMM)

Multimodal monitoring approach improves ability to detect hypoperfusion in the injured brain

Accuracy of brain multimodal monitoring to detect cerebral hypoperfusion after traumatic brain injury.

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New paradigm – quantitative brain function monitoring

Electroencephalography as a Prognostic Tool after Cardiac Arrest.

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Summary

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Master Class: AKI and RRT #EuAsia18

EuroAsia 2018, Renal

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Diagnostic workout of AKI

KDIGO guidelines http://kdigo.org/guidelines/

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Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.

https://www.ncbi.nlm.nih.gov/pubmed/26162677

Basic investigation for all AKI

  • Renal ultrasound
  • Ca
  • Biochemistry
  • Urinalysis – microscopy and electrolytes

The subsequent tests are guided by the clinical picture and history

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A prospective evaluation of urine microscopy in septic and non-septic acute kidney injury.

https://www.ncbi.nlm.nih.gov/pubmed/21669886

Renal biopsy can be diagnostic and can provide information about background histology. 85% of pts develop peri-renal haematoma.

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Future – renal biomarkers

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Summary

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When to start and when to stop RRT

Does this patient with AKI need RRT? https://www.ncbi.nlm.nih.gov/pubmed/26690077 

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Strategies for the optimal timing to start renal replacement therapy in critically ill patients with acute kidney injury. https://www.ncbi.nlm.nih.gov/pubmed/28222898

Renal replacement therapy in critically ill patients with acute kidney injury–when to start.

https://www.ncbi.nlm.nih.gov/pubmed/22231034

The optimal time of initiation of renal replacement therapy in acute kidney injury: A meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620297/

Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial.

https://www.ncbi.nlm.nih.gov/pubmed/27209269

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit http://www.nejm.org/doi/full/10.1056/NEJMoa1603017

 

When to stop –

  1. Has the original precipitant for the AKI resolved?
  2. Is there evidence of some degree of recovery of kidney function?
  3. Has any fluid overload been resolved?

Can this patient be safely weaned from RRT?

https://link.springer.com/content/pdf/10.1007/s00134-017-4948-0

 

The terms ‘early’ and ‘late’ RRT should be replaced with TIMELY RRT

Furosemide stress test/challenge test – 0.5-1mg/kg.

 

How to select mode of RRT

Depends on resources, where you work

Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study

https://jamanetwork.com/journals/jama/fullarticle/201386

Intermittent versus continuous renal replacement therapy for acute renal failure in adults: cochrane review

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003773.pub3/full

 

Modality on mortality – no strong data to support continuous or intermittent RRT

 

Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

http://www.nejm.org/doi/full/10.1056/NEJMoa0902413

Nice comparison of IHD vs CRRT vs SLED https://lifeinthefastlane.com/ccc/ihd-vs-crrt-vs-sled/

 

The dose of RRT

No benefits to higher intensity RRT

Target 25ml/kg/hr

 

Drug dosing during RRT

Does anyone adjust drug dosing when pt is on SLEDD? If so, how? Even the pharmacist disagree on what to do – Survey of pharmacists’ antibiotic dosing recommendations for sustained low-efficiency dialysis. https://www.ncbi.nlm.nih.gov/pubmed/26499505

SaMpling Antibiotics in Renal Replacement Therapy (SMARRT): an observational pharmacokinetic study in critically ill patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773999/