ISICEM 2015 - Blog
Follow @avkwongAuthor: Adrian Wong - Clinical Fellow ICM/Echo Oxford Deanery
Edited by: Steve Mathieu
ISICEM 2015 18/3/15 – DAY 1
International Symposium on Intensive Care & Emergency Medicine in Brussels
Opening Plenary Session
Say YES to intensive care (J-L Vincent)
Setting the tone on the 35th anniversary of the ISICEM meeting
In the last 35 years, as a specialty, we are doing less and less e.g. transfusion, fluids, tidal volumes.
A cautionary note on the endless pursuit of EBM via RCTs. There are a lot of ‘negative’ RCTs (I personally hate the term ‘negative’ trials. It plays done the huge effort put in by the research team). Patients on the ICU are very heterogenous and hence are we surprised that one size doesn’t fit all?
Perhaps a more positive view point is the fact that although mortality is static, the age of our patient has increased. The burden of ICU care should not be underestimated. Patients may benefit from earlier intervention rather than banging on death’s door before being admitted. Accessibility to ICU care needs to be timely.
Closing note – realise the difference between protocolised care vs intelligent care.
Reducing the global burden of sepsis (S Finfer)
Highlights from the roundtable discussion on understanding the burden of sepsis in the global context.
Areas to be tackled
- Understanding its epidemiology. Data is scarce from countries in Africa and Asia. Global Burden Of Disease Study - http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61682-2/abstract
- The impact of our changing world on the disease
- Ageing population
- More mobile population/Urbanisation
- Antibiotic resistance
- Measures to manage sepsis
- CVS optimisation
- Infection control
- Modulation of sepsis response
- Morbidity the price of success
With improved data we can also improve awareness among health care workers, the public and politicians (World Sepsis Day 13th Sept)
Sepsis success:
1 Reducing case fatality rates in many countries
2 World Sepsis Day and increasing awareness
3 Hand hygiene and prevention initiatives
4 High quality investigator initiated research
5 International/global collaboration on many fronts
What did you ProMISe? (K Rowan) LINK
The last in the trilogy of EGDT trial.
Conclusion
Primary outcome
• No difference in all cause mortality at 90 days in EGDT vs usual care (29.5% vs 29.2%)
Secondary outcome
• SOFA score at 6 hours and 72 hours: higher SOFA scores in EGDT but that is due to intervention
• Receipt of organ support in critical care: More CVS support in EGDT
• Duration of organ support in critical care: No difference
• Duration of stay: No difference
• All cause mortality: No difference at 28 days, hospital discharge and at 1 year
Pooled data (Protocolised Resuscitation in Sepsis individual patient data Meta-analysis) – NO DIFFERENCE IN 90 DAY MORTALITY
In adults, presenting to ED with signs of early septic shock, identified early and receiving IV antibiotics and adequate fluid resuscitation – haemodynamic management according to a strict EGDT protocol does not lead to an improvement in outcome.
Transfusion - does the age of RBC matter? (P Herbert) LINK
Fresh (less than 8 days) RBCs vs standard RBCs in order to improve 90 day mortality and morbidity
Fresh red cells do not appear to be superior to standard issue red cells in critically ill patients
SIRS is dead (R Bellomo) LINK
The original definitions of SIRS/Sepsis are now more than 20 years old
Problems with the definition:
- Terminology does not help us understand the underlying problem
- SIRS is too sensitive but is not specific
- SIRS does not reflect the severity of the disease process
- SIRS may detract from the search for infection
Patients can have severe sepsis without SIRS i.e. limited sensitivity and yet they have features of major illness
There is no step-up in risk at having 2 SIRS criteria compared to 3 or 4 – lack construct validity
Sepsis 3.0 (Singer)
Host response is key
Sepsis is not simply a systemic inflammatory response
Variety of anti-inflammatory and other (mal)adaptive responses occur concurrently
Sepsis should be defined as life-threatening organ dysfunction due to a dysregulated host response to infection
Sepsis = really sick infection
No definition is data driven using SOFA score to characterised organ dysfunction
SOFA superior in ICU but poor on ward and ED.
qSOFA – altered mental status, respiratory rate and systolic BP is superior on ward and ED
Personalised medicine in the future (H Wong)
Precision Medicine Initiative - http://www.nih.gov/precisionmedicine/
ICM deals with syndromes and hence needs personalised care
Current diagnostic tests to define subclasses/endotypes of critical illness are too slow
Future would involve multiplate mRNA testing to allow customise therapy based on biologically-defined endotypes
Should we centralise ICU care?
Advantages and problems (D Angus)
Existing critical care
- Expensive, poorly distributed and stretched thin
- Care May be better at larger centres
- Regionalised trauma systems demonstrate potential
- But, critical care is more complex than trauma
- Regionalising critical care: Potential benefits; Some aspects are not that hard, once incentives aligned
- Demonstrate projects
- Regional centres
- Telemedicine
- Community/Interhospital outreach
- Hybrids
- Areas of future research: Reasons for volume outcomes; Alternative staffing models
ECMO Centres (A Combes)
- Only experienced centres should run ECMO programmes
- Both VA and VV ECMO, at least 20 cases per year
- Create regional networks of hospitals
- Detect early refractory cardiac/respiratory failure
- Mobile ECMO retrieval tams in all ECMO centres 24/7
Trauma Centres (O Grottke)
Probably the most established regionalised/centralised service
Right patient at the right place at the right time for the right treatment
Benefits have been replicated in studies across the globe
Cardiac arrest centres (J Nolan)
Aim is to maximise myocardial and neurological recovery
PROCAT Registry (http://www.ncbi.nlm.nih.gov/pubmed/20484098) In OHCA patients with no obvious extra-cardiac cause, a significant proportion will have abnormal coronaries found at angiography.
Prognostication post cardiac arrest - http://www.ncbi.nlm.nih.gov/pubmed/25398304
Summary
▫ Logical progression of existing regionalisation
▫ 24/7 access to cardiac cath lab
▫ Comprehensive post-resuscitation care
▫ Neurological support for prognostication: SSEP, NSE, continuous EEG
▫ Indirect evidence for better outcomes
▫ It’s happening anyway!
Early resuscitation is sepsis
What do you mean by early (J Bakker)
Earlier is better
▫ Defibrillation in cardiac arrest - http://www.nejm.org/doi/full/10.1056/NEJMoa0706467
▫ Antibiotics - http://www.ncbi.nlm.nih.gov/pubmed/16625125
▫ Early admission to ICU - http://www.ncbi.nlm.nih.gov/pubmed/17167350
The effect of goal-directed therapy on mortality in patients with sepsis - earlier is better: a meta-analysis of randomized controlled trials LINK
Targeting blood pressure (JL Teboul)
Hemodynamic variables related to outcome in septic shock - http://link.springer.com/article/10.1007/s00134-005-2688-z
Use vasopressors even when hypovolaemia has not been completely resolved
Target higher BP if
▫ Normally hypertensive
▫ Elevated CVP
▫ Increased abdominal pressure
SEPSISPAM
Still a place for transfusion (A Perner)
More pts transfused in EGDT vs usual care groups –
▫ PROCESS – 14 vs 8%
▫ ARISE – 14 vs 7%
▫ Rivers 64 vs 19%
TRISS
How to prevent renal failure (R Bellomo)
Preventing AKI in sepsis
▫ Do not give starch
▫ Do not give gelatin
▫ Do not give NSAIDs
▫ Do not give multiple doses of aminoglycosides
▫ Do not give long courses of vancomycin
▫ Do not give amphotericin
▫ Consider giving chloride-poor or chloride physiologic fluids
Conclusion
▫ In septic patients renal protection remains elusive
▫ Avoid nephrotoxins
▫ Probably best to maintain a MAP close to basal night-time levels
▫ Avoid fluid overload
▫ Consider vasopressin
▫ Consider global (patient) costs
▫ Killing the patient while trying to save the kidney is not a good idea
Improving sepsis performance in the ED (F Machado)
Describe the challenges of implement a change in practice in the ED with regards to sepsis management
Key – multifaceted approach to get people to do what they agree to do e.g. education, training, incentives, etc.
Improving sepsis performance on the ward (R Dellinger)
Quality improvement project to roll out SSC bundles on the wards in a US hospital
Nurses empowered, electronic notes/warning systems
Pharmacist ensures antibiotics are administered within 15 minutes of being prescribed
The essential haemodynamic variables
Interpretation of heart rate (A Morelli)
Tachycardia can be compensatory or non-compensatory
Compensatory mechanisms are only useful over a short time frame
Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock A Randomized Clinical Trial]
Arterial pressure (S Magdar)
Step 1 – observe patient. If patient is fully awake, communicating, good colour, urinating, normal BE/lactate, their BP is likely to be adequate. Observe
Summary
- We are pressure regulated species – arterial pressure is relatively constant under normal conditions
- Volume and compliance determine the pressure
- CO and SVR determine the central pressure. Central pressure determines the regional flow.
- Total energy NOT pressure determines flow – gravitational, elastic and kinetic
CVP (M Cecconi)
FENICE Trial Protocol - http://www.esicm.org/upload/Protocol_FENICE07_11_2012Final.pdf
http://www.esicm.org/research/fenice
Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. http://www.ncbi.nlm.nih.gov/pubmed/23774337
Conclusion
▫ CVP is an important variable as it is key determinant of venous return
▫ Best interpreted when look at: Changes CVP; Concomitant changes in CO
How to measure pressure accurately (JL Teboul)
How to measure pressure accurately (JL Teboul)
Errors in CVP measurement - http://www.ncbi.nlm.nih.gov/pubmed/19299788
Sources of error
▫ Inappropriate zero point (anatomical)
▫ CVP measured at the foot of c wave
▫ CVP and PAOP are measured at end-expiration – will thus depend on SV or IPPV
▫ Subtract the estimated PEEP/auto PEEP
How to measure cardiac output accurately (X Monnet)
Dilution techniques are accurate and should replace PA catheters as the goal standard
Uncalibrated pulse contour analysis
▫ SV proportional to amplitude of aortic pressure
▫ Relationship is influenced by vascular compliance and resistance. Hence are unreliable in case of changes in vasoactive tone
Volume clamp method e.g. NEXFIN are not very accurate in the ICU setting
CO is not regional blood flow, nor tissue perfusion, but only a part of it
Blogs for day 2 and 3 of the conference can be found on the OXICM Blog - click links below
ISICEM 2015 BLOG DAY 2
ISICEM 2015 BLOG DAY 3