Wessex ICS Blog

Scottish Intensive Care Society Meeting

Meeting: Scottish Intensive Care Society
Venue: St Andrews
Date: 21st-22nd January 2016
Summary blog by: Dr James McNicholas

Screenshot 2016-01-29 18.05.56

Trade stands

• Cook: the Melko set combining surgical and percutaneous kit for emergency cricothyroidotomy is now a standard in Scottish ICUs
• Cook: there exists a ‘staged’ intubation kit with which it is possible to leave a thin wire in the trachea post extubation, for several days; reintubation is by railroading an exchange catheter and then an ET tube at induction; there are case series reporting practicality and ease of use.

Professor Sean Bagshaw (Alberta, Canada): acute kidney injury

• MIMIC II project (Liborio et al) showing that renal replacement reduces mortality in patients who have AKI plus complications (being hyperkalaemia, fluid overload and metabolic acidosis).
• Chronic kidney disease confers vulnerability of CVS, RS, GI, Immune, haematologic systems.
• CKD is more likely if AKI is repeated, severe and protracted (surprise, surprise).
• AKI increases later risk of: severe sepsis, VZV infection, TB reactivation, fracture risk (loss of bone strength) and cancer risk; it must be an immune organ.
• No evidence for diuretics, dopamine, BNP, ANP, fenoldopam, NAC, remote ischaemic preconditioning in either prevention or mitigation.
• NCEPOD 2009: 50% of AKI care was ‘poor’.
• Glasgow study: 4 fold increase in mortality for AKI patients.
• Dutch study (Colpaert et al) showing that e-alert improves response time to intervention in AKI (but not outcome).
• Cincinnati study showing automated alerting of AKI risk dramatically reduces exposure to nephrotoxins.
• Derby et al: e-alert linked with ‘care bundle’ for AKI (disruptive alert!!); only 12% compliance with the bundle (!); ‘there was improved mortality and other outcome measures associated with completion of the bundle’.
• Timing of CRRT: debated since 1961; STAART - AKI trial will look at early (within 12 hours) versus standard (only with classic criteria) initiation of CRRT. “Looking for collaborators…”

Professor Tim Walsh (Professor of Critical Care, Edinburgh University)

• Unnecessary deep sedation is bad (Jackson et al)!
• Early deep sedation is bad (Shehabi et al).
• Kress et al: daily sedation hold is good.
• DESIST study presented: educational intervention certainly improved knowledge and probably sedation quality; RI monitoring appeared to improved optimum sedation, less agitation and dyssynchrony (no protocol, simply awareness of the figure); they conclude that RI can improve overall optimum sedation; quality feedback does not improve optimum sedation; they recommend the web-based education tool become standard, that sedation-analgesia quality should now be tracked, that RI monitoring trial should be repeated in isolation as a straight RCT. Comment: a very complicated study design; notwithstanding that, a free educational intervention about sedation might well be of benefit and we might want to consider it at Portsmouth.

Professor Peter Andrews (Edinburgh)

• Hypothermia and protection of the brain in TBI
• Cellular preservation by hypothermia is not in doubt, and physiological mechanisms are very clear
• Evidence of protection in post cardiac arrest and neonatal HIE mentioned as part of rationale for study in TBI
• Nielsen 2013 (33C v 36C) also mentioned; importance of protocolised care emphasised, and perhaps even the deliberate prevention of early prognostication, inherent in TTM.
• EUROTHERM 3235 trial: inclusion of adults, closed TBI, ICP > 20 after simple first line treatments (stage 1), abnormal CT; randomisation to normothermia or controlled temperature 32-35C for > 48hours (stage 2); stage 3 option of barbiturate coma or decompressive craniectomy; outcome measure GOSE; stopped early for ‘futility or trend towards potential harm’. Comment: expensive (£2,000,000), but at least we know not to do it now!

Dr Ross Patterson (safety and risk)

• Scottish SMR has fallen consistently since 2007, both ICU and hospital.
• Importance of bundles emphasised in achieving practical safety improvements
• Importance of sharing innovations and improvements
• Targets for quality improvement should be high volume, with large variation and high cost

Dr Rhona Flin - Psychologist


• SFRM behaviours: situation awareness, conflict management, leadership, followership, communications, teamwork and cross-cultural awareness were discussed.
• Adverse behaviours impact patient safety.
• Power of cognitive and social skills to reduce error and adverse event.
• Argument was presented that a cycle of examining non-technical skills expertise in a given centre, identifying problems and implementing solutions can improve safety, including in intensive care.
• Anaesthetists Non-Technical Skills System Handbook (ANTS).
• Non-Technical Skills for Surgeons (NOTSS).
• CRM is equally important for routine activity as it is for high-pressure emergencies.
• Effects of experiencing rudeness at work; ‘the experience of rude or aggressive behaviour is to reduce cognitive performance’; also ‘witnessing a rude or aggressive exchange can impair cognitive performance”.
• CRM/NTS training can lead to a significant reduction in errors; important for both senior and junior people.
• The best behaviour should be inculcated at the most junior level, medical school; seniors must model good behaviour.
• Comment: excellent presentation, which was highly persuasive about the value of non-technical skills and training for them, in the promotion of a culture of safety and quality.

Dr Stephen Cole (SICSAG)

• Benchmarking organization for Scottish ICM (equivalent to ICNARC).
• Problems discussed: difficulty of SMR outliers, including triggers for investigation, rigour of investigation and sustainability of process; delayed discharges; APACHE II recalibration in 2008; ICU mortality and hospital mortality have fallen in Scotland over the past 20 years.

Frailty in ICU

• Multi-dimensional syndrome related to ageing; function of physical reserve
• Prediction: 9 level frailty score (1 = fit, 9 = terminally ill)
• Frailty did not correlate with APACHE 2 score (no stats)
• Frailty appeared to correlate with ICU mortality (no stats)
• Comment: well worth a larger observational study (MIMIC 2?).

Dr Chris Hawthorne: CHART-ADAPT

• Aridhia AnalytiXagility technology reduced data processing time of 16 hours to 48 min.
• Funded by Innovate UK (non-commercial)
• Active real time analytics of waveform resolution data, at a frequency of 60 Hz!!!
• Comment: this is proof of process and is the first UK centre (to my knowledge) to be leveraging clinical ICM data in this way; my prediction is that this will become standard within a relatively short time, and its ability to influence outcomes will be huge.

Professor Charles Hinds: Heterogeneity of the response to sepsis

• Limitations of the science were offered: failure of animal models; limitation of the understanding of sepsis; poor clinical trial design; sepsis is an ill-defined clinical syndrome, the definition of sepsis may not be right.
• And…the host response to sepsis is very heterogeneous.
• Individual genomic diversity, source of infection and infecting organism are all sources of heterogeneity.
• Genomics:
o hypothesis generated studies were inconclusive, mannose-binding lectin polymorphisms seemed to be related to sepsis in small studies, but not found to be important in a large study in adults; may be important in infection with pneumococcus
o genome wide association studies in sepsis; GenoSept study; CAP or peritonitis; 1770 patients genotyped; FER gene associated with survival from sepsis, coding for a tyrosine kinase in cells which you would expect to be associated with susceptibility to sepsis
o gene expression is also known to be different in control and septic patients; unsupervised hierarchical cluster analysis showed that there were very clearly different clusters with a highly significant difference in mortality (i.e. gene expression differs between survivors and non-survivors of sepsis); 3080 genes were differently expressed between the clusters; 7 genes could be used a priori to determine into which cluster a patient would fall; the poor outcome is conferred by immune suppression; they conclude that early gene expression can define a sub-population of immune suppressed patients with a poor outcome in sepsis
• Source of infection:
o There is a considerable variation in gene expression between CAP and peritonitis
o “the source of infection influences the host response”
• Infecting organism:
o The pattern of gene expression is very different between viral pneumonia and bacterial pneumonia
o Host gene expression can distinguish between infecting bacteria and between bacterial and viral pneumonia!!
o “key pathways in sepsis differ between the infecting organism”
• Overall conclusion is that we should begin to adopt a ‘personalised’ approach to treating patients with sepsis: what works for one patient with S Pneumoniae CAP, may not work for another.
• Speculative suggestion: define 7 gene set and identify cluster, treat immune suppressed group with a “stimulant”!!
• Implications for trials: homogeneous cohorts; immune function; genetic predisposition; we should abandon trialling interventions in all septic patients and focus on sub-groups.

Dr Nazir Lone: the ageing population

• Increasing population of elderly and frail patients with increasing expectations
• King’s Fund say: people have higher expectations of standards of care, more information, latest treatments
• 30% of over 80s are alive 1 year following ICU admission (so not no one!)
• Outcomes are worse for ‘the average’ older patient, but not terrible
• Comment: demographics seemed comparable to ours
• There is regional variation in incidence of admission to ICU in the over 80 year old group – not clear why?
• For pneumonia admissions, the >80 cohort have much less comorbidity than younger patients with identical acute physiology score (APACHE 2 less chronic health part), clearly indicating that we select out elderly patients with co-morbidity and acute physiological derangement; they also have higher mortality despite lower co-morbidity, which suggests it may be correct to select them out!

• Legality: 2010 Equality Act gives ‘age’ as one of nine protected characteristics; healthcare is not exempt from this; comment; so in principle a 90 year old with hepatic failure could challenge a decision to decline transplantation.
• DJ case discussed: Court of Protection ruled that a man who was 8 months on a ventilator with HIE with repeated septic episodes should not have limits placed; Court of Appeal overturned that decision; UK Supreme Court subsequently ruled that the Court of Protection judgement was correct and NOT the Appeal Court judgement.
• Guidance: we should try to establish ‘best interests’ by consultation with the family, to establish what the patient would want; that it may be rational for someone to choose to live a comatose life on a ventilator!!!
• Recovery does not mean a return to full health, but rather return to a state of health, which they would feel worthwhile.
• DNAR: should be discussed with family at any time of day or night; the standard is not whether it is inconvenient, but whether it is practicable.

Professor Sean Bagshaw: frailty in ICU


• Multi-dimensional state highly correlated with the ageing process, characterised by a loss of reserve, both physiological and cognitive; eventually becomes overwhelming.
• Diminished repertoire of homeostatic responses
• Chronic insufficient nutrition; decreased energy expenditure; decreased metabolic rate; sarcopenia.
• Measurement: 8 dimensions being, physical activity, nutrition, energy, strength, cognition, mood, mobility, social engagement; 20 different assessment tools.
• Frailty represents the “cumulative effects of individual deficits”.
• Frail phenotype: weight loss, decreased grip, slow walking speed, self-reported exhaustion, low physical activity; >/=3 is frail.
• Frailty predicts poor surgical outcome (Makary et al); increased complications, increased length of stay, 20 fold higher relative risk of post-operative institutionalisation (elective surgery).
• Once admitted to the ICU there does not appear to be a difference in intensity of support; death in ICU was not different in one study (Lone), though death in hospital was higher.
• Predictors of frailty: pre-hospital institutional residence, presence of connective tissue disease, female gender, disability assistance, and previous recent hospital admission.
• How is frailty scoring useful to us:
o Better informed ICU triage information
o Better informed decision-making in ICU; scope of support, time-limitation, information about survivor status including new disability or institutionalisation
o Transitions of care: specialized needs for transfer from ICU to ward and from ward to community
o Interventions to maximise recovery potential including rehabilitation needs; cognitive stimulation, exercise training, nutritional supplementation, pharmacology (minimise unnecessary drugs, give testosterone?)

Professor Charles Hinds: goal directed therapy

• Historical tour of GDT in the 70’s talking about the Shoemaker studies.
• Hypothesis of targeting CI>4.5, DO2 > 600 ml/min/m2
• Concept of oxygen debt revisited; supply dependent O2 consumption mentioned
• No persuasive RCTs in that period and the flaws of the published studies were discussed; one such being stopped for harm.
• Comment: none of these studies would meet modern criteria for publication.
• Reminded that the ability to achieve supra-physiological goals is a marker of health, not a function of deliberate intervention.
• EGDT (Rivers): reminded that this was aiming to achieve physiological CI, not supra-physiological; not AS flawed as the previous work.
• Flaws of the subsequent studies mentioned: early aggressive fluid and antibiotics were given to all patients, potentially obscuring the value of targeted therapy.
• Importance of the microcirculation discussed.
• Optimise study: statistical significance NOT achieved
• Recommendations: early, rapid and effective volume resuscitation, correct low cardiac output, use dynamic measures of fluid responsiveness, measure microcirculation (?)
• Comment: future scoping included a suggestion that we should be looking to classify patients into sub-groups for research and to individualise the resuscitation regime.

Professor Jean Chastre: pulmonary infections

• VAP v VAT v VA Complication; new microbiology; PK/PD optimised antimicrobials; aerosolised antibiotics; non-antibiotic approaches.
• VAP v VA Tracheobronchitis v VA Complication: VAP requires new or progressive pulmonary infiltrate with observation of infectious signs and positive microbiological culture results; VAT requires only evidence of inflammation (SIRS) and microbiological criteria, without CXR features; reminded that the use of antibiotics in simple colonisation of the upper airways is harmful and results in massive overuse; VA Complication requires a period of stability, followed by a deterioration of oxygenation, and becomes Infection-related VAC when SIRS occurs AND an antibiotic is given, and then probable VAP when microbiological results are positive. VAC advocated as preferable definition to VAT.
• New advances in microbiological approach: MALDI_TOF mass spectrometry may provide same day diagnostics; but there is no sensitivity data with this technique; it was suggested that combining MALDI_TOF plus direct conventional antibiograms may provide both within 24 hours of sampling.
• Pharmacokinetic/Pharmacodynamic-optimized antimicrobial therapy: argued that without monitoring we often fail to achieve maximum benefit from our antibiotic use. Value of antibiotic infusion versus intermittent bolus was explored. Comment: some evidence for net benefit, and some of no benefit, but no account of cost-benefit. Infusion is harmful for beta lactams if the MIC is never achieved.
• Aerosolisation: very difficult to accomplish delivery of the correct size of droplet, though technology is improving; there are several ongoing clinical trials of this approach.
• Non-antibiotic approaches: theory only at present; targeting bacterial virulence factors, rather than trying to eliminate the bacterium; MAbs against bacterial virulence antigens; ongoing trials, which are inviting participating centres.
Dr Peter Keston: Neuroradiological intervention in brain injury

• ISAT trial showed coiling safer than clipping in brain aneurysms; technology has improved since then.
• Ischaemic stroke: intra-arterial tPA was described, as well as the snare, penumbra and catch devices; IMS III study 2014 showed no evidence of benefit with intervention for any device; stent retriever is now being widely used with good reperfusion results.
• Very effective intervention for those who have: acute severe stroke, large vessel occlusion and presentation within 6 hours.

Dr Tim Wigmore: Royal Marsden, Haematological-oncology patients

• Outcomes in ICU admission haematological oncology patients across the UK have improved year on year since the 90’s; unit mortality for all such patients (ICNARC) is about 40%.
• What has changed: new drugs, GCSF, new antibiotics and antifungals; new diagnostics and therapeutics, to include less ablative oncology treatments.
• AML: ICU survivors have the same 5-year outcome as non-ICU admissions.
• Who benefits from ICU admission (where benefit is ICU survival)?
o For prognosis, do not use: disease prognosis (as opposed to performance status); neutropenia; sepsis; recent chemotherapy; none of these commonly quoted ‘risk’ factors influence your mortality risk
o consider ‘giving acute chemotherapy in a critically ill untreated acute leukaemic’, because it is the leukaemia that will rapidly kill
o poor prognosis is associated with: poor performance status; invasive fungal infection; bone marrow invasion; in hospital cardiac arrest
o unsurprisingly 3 organ failure for more than a few days is bad (like non-cancer patients)
o it is definitely NOT true that ventilated haematological oncology patients all die, as is sometimes said; don’t leave it until they are peri-arrest; failed NIV is associated with high mortality, but this was attributed to ‘leaving it too long’, the outcome being worse than for those intubated earlier
o scoring systems were not felt to be helpful for these patients
o poor outcome is indeed predicted by: Allograft BMT who has GVHD; increasing age; recurrent malignancy; respiratory failure that is NOT infectious in aetiology.
o Delayed intensive care, presentation and admission, is associated with increased mortality in this group
o Don’t admit: bed ridden; very poor cancer prognosis; patient refusal.
o Do admit: previously untreated, tumour lysis, those in remission.
o All others: 4-day trial of admission!

The sick HIV patient: Dr Alisdair MacConnachie

• Anti-retroviral therapy confers ‘near normal’ life expectancy and there is therefore no excuse for failing to test if there is an indication to do so.
• Presentation covered: recognition; natural history; anti-retrovirals; infections (PCP, pneumococcus, TB); HIV testing and consent.
• Recognition and natural history: natural history described; usually progresses to death over 8-12 years;
o acute syndrome occurs within 2-4 weeks after infection, feels like glandular fever, usually sub-critical but can be lethal; may be a role for acute use of anti-retroviral therapy, particularly in the critically ill group
o latent period, with progress measured by CD4 count
o CD4 counts falls and symptomatic HIV infection develops (VZV, Candidal infection, HSV, EBV, seborrhoeic dermatitis, LNs, molluscum, diarrhoea, anaemia, lymphopenia, thrombocytopenia)
o Opportunistic infection: PCP, TB, toxoplasmosis or Cryptococcus in brain, PML (stroke syndromes), CMV retinitis or oesophagitis
• Anti-retrovirals:
o Anti-retroviral therapy is now very effective and increasingly less toxic; beware drug interactions
o Increasing evidence for starting anti-retrovirals as soon as the diagnosis of HIV is made
• Infections:
o PCP: profound hypoxia, especially in exercise challenge, classic CT, diagnosis on BAL (or sputum); treatment with septrin, or pentamidine, or clindamycin with primaquine, or atovaquone; PLUS prednisolone 40mg bd if there is hypoxia
o PCP: there is good evidence for starting anti-retrovirals early, including in PCP admission, including where they are ventilated! Don’t delay.
o Pneumococcal invasive disease: much commoner in HIV+ patients over HIV- patients; should probably test patients with SP in blood for HIV (in London 20% of people with SP in blood are HIV+)!
o TB: recurrence of TB is intimately related to HIV; TB promotes HIV progression, there is positive feedback between TB and HIV; commoner presentation of extra-pulmonary disease in HIV+ patients; integrated early treatment of both HIV and TB in a presentation with TB is associated with better survival at 2 years (within the first 2 months).
o HIV testing: conventional risk factors should not guide the decision to test, because it is felt that many undiagnosed HIV+ people have no conventional risk factor, and it is certain that many people diagnosed with HIV do not have a conventional risk factor.
o HIV consent: GMC guidance states that you must get consent; unless they cannot give consent in which case you can test if it is in their best interests (though you may be challenged subsequently).

Summary: a superb meeting with very high calibre speakers.

Take homes:
• Most of what was presented is consistent with what we already do
• Over sedation is bad (no surprise)
• SMR is falling consistently for a decade, meaning benchmarking metrics require recalibration, so we must be doing something right
• CRM training can reduce error
• Data science is beginning to influence the conduct of clinical research in critical care (two presentations referred repeatedly to the technology).
• There is attention being given to the active quantification of frailty
• Future improvements in sepsis care may depend upon genetic typing of different cohorts, with different immune phenotype and response to the same septic insult.
• GDT – nothing new!
• Haematological oncology patients: performance status is probably the best way to discriminate ability to benefit and each case should be judged without preconception (including BMT).
• Interventional radiology can now offer a very effective intervention for early large stroke (last 12 months).
• Treated HIV patients in some centres now have a statistically better life expectancy than age matched controls!

These notes were recorded contemporaneously at the meeting, and have not been verified in any published material; any factual inaccuracies or misunderstandings represented in these notes are therefore entirely my own and readers should check the facts independently before quoting them.

Screenshot 2016-01-29 18.06.06



Comments

Delivering an ICM Regional Teaching Programme

Facilitators: Steve Mathieu & Matt Williams
Meeting:
FICM RA/Faculty Tutor Day
Venue:
RCOA
Date:
11th January 2016
Summary blog by:
Steve Mathieu

Screenshot 2016-01-09 17.22.05

Slides available here:

GPICS recommendations for ICM teaching programme

A minimum of 30 hours during each year of regional training is required for those in dual, joint and solo ICM training programmes. These training sessions need to be of a high quality, and formal feedback should be collected and acted upon. They should be mapped against the ICM curriculum in order to provide a wide range of clinical, ethical, managerial and other topics. The teaching programmes should be published well in advance, and each department should help facilitate trainee attendance when constructing a rota and when approving study-leave requests.

Download the full GPICS document
here

Background - the Wessex story


We commenced a programme in 2008. Run monthly since. Consultant co-ordinator. For the last 5 years a trainee to co-coordinate
  • guide written as template for the facilitators to follow model
  • template reviewed annually, taking into account curriculum, exam and trainee feedback
  • considered pre-FFICM and post-FFICM, but rejected
  • started with about 18 joint trainees
  • 33 in training presently (5 single, 2 EM, 2 medicine; 13 joint)

Matt Williams has been the consultant lead facilitator for our regional teaching programme since 2008

The guide for the facilitators


Wessex Intensive Care Medicine (ICM) CCT trainees teaching programme

Consultant lead facilitator: Dr Matt Williams
Trainee lead facilitator: Dr Phil McGlone

Guidance for facilitators:

The trainee facilitator should take primary responsibility for the allocated session with support from the Consultant facilitator. The trainee should initiate contact at least 2 months prior to the teaching date (preferably with suggestions of topics and speakers, having reviewed the relevant sections of the ICM curriculum). This will enable external speakers and trainees to prioritise the meetings.

The timetable should be distributed a minimum of 2 weeks prior to the teaching date. This will allow attendees to prepare for the session, including reading any relevant papers circulated.

A summary of the session will be circulated within two weeks of the teaching date by the trainee facilitator. This will be uploaded to the WICS website.

The content of the lectures should follow the ICM syllabus. The trainee should identify the areas of the syllabus covered and reference these in the timetable.

Suggested teaching styles that can be included:
• Review of the recent literature on a topic area
• Case presentations (ideal for case summaries)
• Journal article review
• Expert speaker
• MCQs

It may be pertinent to have part-task or medium fidelity simulation on occasion.
Ideally there should be two or more trainee speakers at each session. External speakers may lend themselves very well to a particular session. Primarily trainees should be taking an active role in presenting and teaching. This responsibility should be shared amongst the group over the course of the programme.

Ideally there should be at least one senior (ST6/7) and one more junior (ST3/4/5) ICM trainee presenting at each session.

To encourage positive responses from the trainee group, it is suggested that the trainee facilitator asking people to present should cc the consultant facilitator into the requesting email.


It is up to the trainee to ensure all the equipment required for the session is in place and working prior to the session.

Attendance:

The ICM Training Programme Director (supported by Specialist Training Committee) has stipulated that ICM CCT trainees must attend the formal training programme throughout their joint/single/dual training.

Paperwork:

Any questions or suggestions should be directed to the Lead Facilitators please.

Content


Curriculum based
20 minutes presentations
Pre-reading ‘flipping the classroom’
Considerations:
- Combined vs Pre- / Post- FFICM sessions
- Trainee / consultant speakers
- Other specialties; local & external speakers
- Special Skills modules
Feedback essential

The challenges of delivering a quality teaching programme


Worth considering why it is difficult to maintain the quality of an ICM (or indeed any specialty) regional teaching programme:

  • Curriculum changes
  • Shift patterns are evolving
  • Different learning needs at different stages of training (pre- vs post- FFICM)
  • Trainees may be in non-ICM specialties as part of their training
  • May be geographical and service commitment barriers which restrict attendance
  • Learning styles are adapting. Generation Y understandably demand us to embrace the digital age
  • Voluminous educational material which is not always easily accessible. Reason quality open access resources (FOAMed) are so important

If you do a pubmed search under ‘intensive care’ or ‘critical care’ for 1950 there will be 1 article returned.

Do the same literature search for 2015 and there are 24,000 citations. Let’s say only 1 % are relevant, you would still need to read 50 articles every single week to keep up to date

We therefore need to adapt and take bold steps!

The role of the teaching programme facilitators


Consultants are essential. The programme organiser needs to be aware of the latest curriculum requirements and ensure that content covered is appropriate and achievable. The consultant facilitator is the person that can best assimilate knowledge, appraise it and combine it with their wealth of experience. This is fundamental to the learning process.

A co-facilitator, who is a trainee, is essential so that they can develop non-clinical organisational skills and contribute to maintaining a high quality and relevant session.

Pre-course material (flipping the classroom)


Allows more time for discussion / critical appraisal and tacit knowledge development – skills you just can’t learn from reading e.g. simulation

An example would be from a recent session on expanded case summaries (ECS). The completion of 10 ECS are a UK requirement for all ICM trainees. These are written mini vignettes and focused discussions about core topics in ICM. What are the markers looking for when they review the completed ECS’? I decided to get the trainees to mark 3 examples before the session in order to get a better understanding of this. A useful exercise which was then followed by 6 x 20 minute presentations covering a wide scope of the syllabus (including TTP, refractory hypoxaemia, propranolol overdose and the use of levosimendan)

Promote the teaching session


So you have the content and have organised the date. You now want to make sure everyone attends. A global email will probably suffice but why not use other means of promoting your session. Making the dates easily viewable and getting everyone excited and discussing the content is achievable by using one or more of these applications

G mail + calendar
Website
Twitter
Whatsapp
Slack
Facebook forums

Record


You have an excellent session organised with some top quality and well rehearsed presentations. Why not keep a record so that it can be viewed by others that were not lucky enough to attend (asynchronous learning)?

Options include:
1. Summary blog
2. Podcast – this could be recorded in advance (part of the preparation for your talk anyway) or on the day (? Potential to be a distraction; need good quality and portable recording devices)
3. Videocasts e.g. periscope. Again potential to distract. Consideration of sensitive patient info but if planned well a perfect historical record of the session
4. Share & contribute to Free Open Access Medical Education (FOAM)

Benefits
• Asynchronous learning
• Repository of all sessions wessexics.com
• Promotes you, your department and region
• Why wouldn’t you?

Please do share your examples of challenges & excellence in delivering the perfect teaching programme. Good luck!

Useful resources


Signing up for twitter
Social Media Workshop - ICS State of the Art Meeting 2015
How to get started with twitter
What is FOAMed?
 
ICM
Critical Care Practitioner
Critical Care Reviews
Crit-IQ
EmCrit
JICS
ICM Case Summaries
Injectable Orange
Intensive Care Medicine Working Knowledge (ICMWK)
Intensive Care Network
Life in the Fast Lane
NCCU Education
PulmCrit: Pulmonary Intensivist’s Blog
ScanCrit
SMACC (includes podcasts and videocasts of all conferences)
The Bottom Line

EM, Pre-Hospital and Anaesthesia with ICM
Academic Life in Emergency Medicine (ALiEM)
Broome Docs
Emergency Medicine Literature of Note
HEFT EMCAST
KI Doc
Pre-Hospital And Retrieval Medicine (PHARM)
RCEM
REBEL EM
Resus.ME
Skeptics Guide to Emergency Medicine (SGEM)
St Emlyn’s
The Sharp End

Airway
 Airway cam
 
Imaging
icmteaching 
Ultrasound Podcasts

Podcasts
A list of all the podcasting sites for critical care can be found here

Videocasts
Critical Care Reviews Meeting 2015 
Social Media and Critical Care (SMACC) Video’s

There are many more #FOAMed sites available and the list keeps rapidly growing. You can get more information by doing a search on
google FOAM 

Comments

Obesity

Facilitators: Duncan Chambler & Helen Peet
Venue:
Queen Alexandra Hospital, Portsmouth
Date:
17th December 2015
Summary blog by: Duncan Chambler

Diet & Obesity in Critical Care

Introduction



Is obesity a disease or is it just a lack of will power in lazy individuals!? If it is a disease, then it has a prevalence of 1.9 billion globally. Of this,42 million are children. It has an associated mortality incidence of 2.8 million per year, which is nearly double the mortality from HIV/AIDS and is over 200x the mortality from the most recent Ebola outbreak. This disease affects men and women alike. Here in the UK, five in 10 men suffer from the milder form (overweight) along with four in 10 women. In the USA, prevalence has increased from 10% to 50% in the last 50 years. Although it predominantly affects developed nations, it crosses all borders and communities.

Disease or not, obesity is becoming the greatest threat to humanity’s health. If it is a simple as calories in balanced against calories burnt, then why are we failing to correct our path toward physical, psychological, and economic doom?

obsedity

What’s relevant to us?


Many aspects of obesity are obvious. So many of our ITU patients are overweight or obese it almost feels normal. So what do we need to learn?
We could have talked about drug dosing, but that’s easily summarised: dose most drugs on “ideal weight + 40% of excess weight” and you won’t go far wrong.

Or, we could have talked about airway management, but usually this isn’t to hard if there is adequate preparation: ramp until their ear, sternum and abdomen are about parallel to the floor!

So instead we had two expert speakers who look at the bigger problems: why do people get fat, and what can we do for them (as members of society, the profession of medicine and the specialty of critical care)?


1

2


The history of nutritional advice


As an interlude between the speakers, I presented a brief history of nutritional advice and diets (I confessed my own biases first – I believe sugar is bad and fats may not be so bad).

In 1864, William Banting produced a pamphlet for the public called “A Letter On Corpulence”. Banting had an idea that worked for him, so he wanted to tell the world (these days he would have used Twitter). His high fat and low carbohydrate diet helped him drop weight so effectively it became the popular diet of the time.

In the 1950s and 60s, cardiologists wanted to blame something for coronary disease. Cholesterol and saturated fats became that something after Dr Ancel Keys produced the Seven Countries Study, which strongly associated cholesterol to coronary disease. This evidence, along with a committee in a rush, led to the USDA’s advice and subsequent Food Pyramid, which advises a high carbohydrate and low fat diet. This is still mainstream advice today 50 years later. Take a look at this short YouTube video about the unbelievable
McGovern Report

Only now are we beginning to understand that coronary disease is more complicated than just dietary intake, and eggs are back on the menu!
If you fancy a different way of eating, backed up by science, take a look at The Real Meal Revolution by Prof Tim Noakes.

Why people get fat

Lorraine Albon - Diabetologist at Portsmouth Hospitals NHS Trust with an interest in Obesity Medicine.

Key Points
• Obesity is a problem for healthcare and health professionals: difficult to examine, investigate, nurse and treat; prone to ulcers, VTE and infection.
• Studies have shown negativity, stereotyping and bias against obese individuals by healthcare professionals.
• Is it a disease? A hands-up polls suggests 50% in the room agree whilst 50% think it is simple calorie maths and will power.
• Problems from obesity can be considered as two disorders:

  • a metabolic syndrome associated with multi system disease related to the endocrine and metabolic consequences of excess adipose tissue (e.g. type 2 diabetes, heart disease);
  • a physical syndrome of problems related to the excess body mass (e.g. sleep apnoea, lower back pain)

• Individuals can be fit and fat: mortality hazard ratios for aerobically fit but fat individuals are better than unfit thin individuals.

3

Edmonton Obesity Staging System is better at discriminating those at risk than classical BMI calculation
• The gut is an extensive neuro-hormonal organ and appetite regulation depends upon many hormones, with particular interest currently in Ghrelin and Leptin
• Monogenic and polygenic polymorphisms have been associated with hormone irregularities and consequential obesity – as many as 5% of severe obesity cases may be due to genetic mutations
• At risk groups for obesity include: those who are vulnerable, have limited opportunities and those with large parents; also ex-athletes (who previous ate well and burnt the calories but now continue to eat well without the exercise!), drivers and night workers
• Energy regulation is tightly controlled – within ±1% margin of error

  • One bar of chocolate extra per day = +100 Kcals
  • Equates to 35,000 Kcals extra per year
  • Which would cause 5 kg weight gain per year if not balanced

• Strong evidence exists demonstrating diets don’t work
• Conversely, strong evidence exists supporting metabolic surgery (new term for obesity surgery – the aim is to correct the metabolic syndrome, as opposed to bariatric surgery that is just cosmetic)
• Obesity surgery is commissioned by NHS England as a specialist service, and NICE quality standards will reward trusts through CQUINS for addressing the issue of obesity through a 4-tier management pathway: essentially common advice, specialist nutritional advice, medical advice / drugs and then finally surgery
• Issues relating to ITU

  • Record overweight / obesity as diagnostic text
  • Consider malnutrition and treat deficiencies
  • Consider further assessment: sleep studies, tier 3 referral
  • Warn people about weight loss post ITU

Fat and Malnourished


Denise Thomas is a Dietitian with a doctorate in the study of obesity. She is head of Nutrition and Dietetics at Portsmouth Hospitals NHS Trust.

Key points
• Despite rising obesity rates, food poverty is also increasing
• Recommended eating includes ‘5 portions of fruit & veg per day’, but only 25% of adults achieve this regularly
• High fat and high sugar foods, from take-aways or pre-made meals, are consumed frequently
• A paradox now exists: high energy intake but low nutritional quality
• This is encouraged by agricultural techniques and the low cost of these foods
• Obesity often associated with deficiency of: Vitamins A, E, C and D, selenium, folate, zinc and thiamine

4


• The best advice is to match the Eatwell Plate! With subtle differences to the
USDA’s Food Pyramid in the UK this is the current advice we should give our patients
• If there was one thing society (and government) could do to halt the obesity epidemic, it is to limit and reduce fast-food and take-away outlets
Final Thoughts
We all felt a little disheartened at the size of the problem, the complexity of the science and the uncertainty of the advice. What should we do for our patients when we meet them for just a short period of time? Nudge them with a suggestion perhaps!
• “Have you thought about how your weight might affect your health?”
• “Do you realise that being overweight might make this problem worse?”
From there, if they’re receptive, they can initiate a referral through the 4-tier pathway via their GP!

Christmas Quiz


We concluded the afternoon with a possibly the most academic Christmas Quiz ever, followed by a pint of beer and fish & chips! I guess we ignored all the learning points.
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