Category Archives: EuroAsia2017

EuAsia Day 2: AKI

Epidemiology of AKI and outcome (YS Guh)

AKI characterised by rapid decrease in renal excretory function

Continuum of injury as it develops which corresponds to worsening prognosis

Multiple definitions with limitations e.g. all depend on urine output and creatinine

Most common cause of AKI – SEPSIS

Increase mortality and morbidity in AKI

CKD is a major risk factor for AKI

The quicker pts recover from the AKI, the better the outcome

2017-04-07 10.57.13 2017-04-07 10.56.51 2017-04-07 11.09.29

References

RIFLE criteria for AKI

AKIN criteria for AKI 

KDIGO definitions

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

Recovery after Acute Kidney Injury (2017)

 

Biomarkers for AKI: what, why, how (@erichoste)

Multiple biomarkers available and indicate different things

May be improve the diagnosis of AKI

Not a single delegate in the room uses biomarkers in clinical practice

Interesting but how does it translate to clinical outcomes/management is currently unknown

2017-04-07 11.11.00 2017-04-07 11.23.08

 

Interactions of AKI with other organs (K Chan)

Affects all organ systems

5 types of cardiorenal syndromes

Relationship with AKI and brain is 2 way

2017-04-07 11.31.47 2017-04-07 11.44.21

 

References:

Acute kidney injury: short-term and long-term effects 

Cardiorenal syndromes

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit 

 

Contrast-associated AKI: an issue? (M Ostermann)

Incidence depends on pt groups and criteria for AKI

Most of work done in cardiac patients

Most contrast agents have iodine, high isomolarity compared to plasma and have high viscosity

Impact of contrast – contrast-induced AKI associated with poor short and long term outcomes after PCI for STEMI (HORIZONS-AMI) BUT significant limitations

Newer evidence suggest the risk is for pts who had poor renal function prior OR no risk at all

2017-04-07 12.01.05 2017-04-07 12.13.19 2017-04-07 12.14.31

 

References

Contrast-induced acute kidney injury after primary percutaneous coronary intervention: results from the HORIZONS-AMI substudy.

Acute kidney injury in the critically ill: is iodinated contrast medium really harmful?

Post-contrast acute kidney injury in intensive care unit patients: a propensity score-adjusted study.

Contrast-associated acute kidney injury in the critically ill: systematic review and Bayesian meta-analysis.

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial

EuAsia Day 2: Practical use of fluids in shock in early shock states

Rescue, optimise, stabilise (Cecconi)

CVP – absolute value does not predict fluid responses

CVP changes does not tract CO

ScvO2 in Rivers study was 49%, the modern trials (ARISE, PROMISE) had ScvO2 of 70s

Conclusion

  • Resuscitation can be done with minimally invasive monitoring
  • Goal is always perfusion
  • Being less invasive is not always possible
  • Beware of
    • Technique limitation
    • Accuracy vs precision
    • Haemodynamic strategy vs monitor

2017-04-07 08.13.02 2017-04-07 08.26.20 2017-04-07 08.19.36 2017-04-07 08.18.03

References:

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine

Four phases of intravenous fluid therapy: a conceptual model†

Fluid challenges in intensive care: the FENICE study

Effects of fluid administration on arterial load in septic shock patients

Resuscitation of patients with septic shock: please “mind the gap”! 

Early non-invasive cardiac output monitoring in hemodynamically unstable intensive care patients: A multi-center randomized controlled trial

 

Role of minimally invasive monitoring in fluid management (Xia Di)

Minimally invasive – LidCOrapid, LIDCOplus, FloTrac, etc

Monitor needs to be continuous, fast and able to measure SV

Blood pressure changes can be due to changes in SVR and /or CO – hence the need for a monitor to differentiate

In sepsis, there are 2 problems with regards to fluid management strategy

  • loss of arterial and venous tone
  • fluid status

Positive fluid balance on ICU is associated with poorer outcomes

References:

A rational approach to fluid therapy in sepsis

Reduced mortality with noninvasive hemodynamic monitoring of shock. 

EuAsia 2017 Day 1: ESICM Worldwide

ESICM Education Worldwide (P Gruber)

Education is a essential part of ESICM

An international survey of training in adult intensive care medicine.

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ESICM Academy

 

The benefits of worldwide research network (A Pesenti)

Build a community of Critical Care phycisians and nurses

More people, more ideas

Quick enrolment

Specific for ICU

  • mainly syndromes rather than diseases
  • syndromes are common
  • underlying diseases are rare
  • non-homogeneous population in syndromes

 

Worldwide Intensive Care in the next 20 years (JLV)

JLV predicts (Intensive care medicine in 2050: the future of ICU treatments)

  • Less hospital days, shorter stays – moving pts out of hospital to the community to recover
  • Hospital rooms to become more comfortable and more like your living room
  • Entering room would be computer controlled after handwashed
  • Limits between hospitals and outside will be blurred – more telemedicine
  • Monitors to be miniaturised – biosensor
  • ICUs would make up a bigger proportion of the hospital
  • Death of stethoscope
  • Full extracorporeal support circuit – heart, lung, kidney, liver
  • Automation of numerous processes
  • Personalised medicine

The Future of Critical Care Medicine: Integration and Personalization.

 

 

EuAsia 2017 – Day 1: Respiratory failure and organ interaction

Respiratory failure and organ interaction

Lung failure (S Jabar)

Classical mechanism of damage – volutrauma, barotrauma, biotrauma, atelectatrauma

Low pressure and low volume ventilation but… –> reduces alveolar ventilation

You need to recruit before increasing PEEP

Low TV and high PEEP has a preventative role in the development of ARDS

All ICU patients are at risk of developing ARDS

2017-04-06 08.19.22 2017-04-06 08.18.23

 

References:

Happy 50th birthday ARDS

What’s new in ARDS: can we prevent it?

8 year trends on ARDS

Berlin definition ARDS

 

Pump failure (A Pesenti)

Sick muscle and/or too much work for muscle (they need to work less or to rest)

Measuring auto PEEP – measure pressure at end expiration

2017-04-06 08.25.03

References:

Respiratory Muscle Contribution to Lactic Acidosis in Low Cardiac Output

The role of PEEP in patients with chronic obstructive pulmonary disease during assisted ventilation 

Changes of Respiratory Mechanics in COPD Patients from Stable State to Acute Exacerbations with Respiratory Failure.

 

Diaphragmatic dysfunction (CY Lim)

2017-04-06 09.03.09 2017-04-06 09.07.20

References:

Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation.

Ultrasonography evaluation during the weaning process: the heart, the diaphragm, the pleura and the lung

Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact-a prospective study.

Patterns of diaphragm function in critically ill patients receiving prolonged mechanical ventilation: a prospective longitudinal study

Diaphragmatic dysfunction and respiratory illness (Review)

Evolution of Diaphragm Thickness during Mechanical Ventilation. Impact of Inspiratory Effort.

Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study. 

Effect of theophylline on ventilator-induced diaphragmatic dysfunction

 

Heart Lung Interaction (M Cecconi)

Fluid responsiveness doesn’t mean the pt needs fluids

2017-04-06 09.14.39 2017-04-06 09.26.49

 

The Changes in Pulse Pressure Variation or Stroke Volume Variation After a Tidal Volume Challenge Reliably Predict Fluid Responsiveness During Low Tidal Volume Ventilation* 

Respiratory variation in inferior vena cava diameter: surrogate of central venous pressure or parameter of fluid responsiveness? Let the physiology reply

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

What role does the right heart play?

 

Lungs don’t interact just with the heart (K Zirpe)

Lung open to environment

2017-04-06 09.40.03

References:

Mechanical Ventilation as a Mediator of Multisystem Organ Failure in ARDS

Cardio-pulmonary-renal interaction

Brain-lung crosstalk: Implications for neurocritical care patients

Pulmonary-intestinal cross-talk in mucosal inflammatory disease