https://lives2020.e-lives.org/session/myth-buster-facing-myths

5 False beliefs in acute and chronic respiratory failure

Pr Alexandre DEMOULE

1. ARDS pts should be intubated promptly
2. Intubation can be safely delayed in ARDS patients
3. In COPD, NIV is contra-inducated in case of coma
4. In cancer pts, do everything not to intubate
5. Response to prone position predicts the outcome

ARDS pts should be intubated promptly

• Reflecting on the COVID-19 lessons
• Intubation should be prioritised as delayed intubation causes P-SILI
• A Word of Caution Regarding Patient Self-inflicted Lung Injury and Prophylactic Intubation

Time to intubation has no impact on mortality

• Failure of high-flow nasal cannula therapy may delay intubation and increase mortality
• Noninvasive Positive-Pressure Ventilation To Treat Hypercapnic Coma Secondary to Respiratory Failure

In COPD, NIV is contrainidcated in case of coma

• NOT AT ALL, in cases of hypercapnic coma, do a NIV trial

In cancer pts, do everything not to intubate

• Acute respiratory distress syndrome in patients with malignancies
• Changes in critically ill cancer patients’ short-term outcome over the last decades: results of systematic review with meta-analysis on individual data
• NO BUT do not push too hard, you may harm them…

Response to PRONE position predicts the outcome

When lactate is normal the circulation is adequate

Prof J Bakker

The ten pitfalls of lactate clearance in sepsis

Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock
The ANDROMEDA-SHOCK Randomized Clinical Trial

Conclusions

• The clinical context we create from an increased lactate is: tissue hypoperfusion/hypoxia
  • This is on a macrocirculatory level
• Lactate levels frequently remain abnormal during the first 24h of admission in survivors of septic shock
• Mildly elevated lactate levels are associated with increases in mortality and abnormal microcirculation
• Lactate levels need context
  • Markers of peripheral/microcirculatory perfusion
• Lactate levels do not denote a state of perfusion

Adrenaline improves outcome after cardiac arrest?

Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Conclusion

• Survival to hospital admission x 3 higher
• More survivors to discharge
• More neurologically favourable survivors
• More brain-injured survivors

False beliefs about duration of antibiotic therapy

J De Weale (twitter)

The FALSE beliefs

1. Antibiotic duration needs to be ‘fixed’
   • No Biological rationale
   • Bacteria don’t calculate the days exposed
2. Short courses are less effective
   • Longer courses do not protect against complications
   • BUT some infections do require longer treatment
3. I need a biomarker to determine duration
4. Antibiotics need to be continued until clinical symptoms have subsided
5. An antimicrobial course should always be completed.

Summary

• Inappropriate antimicrobial use in the ICU is unacceptably high
• Duration important contributor
• Management often based on incorrect assumptions
• “7-days course” current dogma for most infections
• Individualized therapy is the future
• AI to refine therapy duration

Prof’s De Weale’s slideset (I like the design)

Prognostication of individual survival chances is not possible? Machine learning is the answer

Prof Mihaela van der Schaar (twitter) www.vanderschaar-lab.com

Machine learning can enable:

1) Delivering precision medicine at the patient level
2) Understanding the basis and trajectories of health and disease
3) Informing and improving clinical pathways, better utilize resources, and reduce costs
4) Transforming population health and public health policy

False beliefs in the management of fever

F Schortgen

Fever is not hyperthermia

Treating fever has never been proven to improve patient comfort

Effect of Shivering on Brain Tissue Oxygenation During Induced Normothermia in Patients With Severe Brain Injury

Antipyresis is NOT necessarily good for haemodynamic stabilistation and tissue oxygenation