Download Updates in ICU

Updates in ICU
Jeremy Fernando
Intensivist and Anaesthetist
Rockhampton
Queensland
My ICU Round
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Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Disclaimer!
Evidence vs Sense
Broad vs Detailed
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Airway
What do you prefer?
• CMAC
• Glidescope
• Handheld Videoscope
Results
Delayed sequence
induction
Preoxygenation
Haemodynamic stability
Cricoid Pressure
Do you use Cricoid Pressure?
• Yes
• No
• Sometimes
Results
High Flow Nasal
Oxygen during
Intubation
“O’s in the Nose”
Emerging data to support its use
Check Lists
Human factors
Infrequent, complex task with risk
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Breathing
High Flow Nasal
Oxygen for
respiratory failure
2L/kg
Can go higher...
...but prepare to
use NIV or
intubate
Evidence for HFNO?
Emerging but not overwhelming
FlorALI – NEJM 2015
Acute Hypoxaemic Resp Failure – Does HFNP vs Facial O2 (standard care) vs NIV
prevent intubation?
23 French ICUs – n = 310
Intubation – 38% vs 47% vs 50% (p=0.18)
90 Day Mortality (Hazard Ratio)
- 2.01 HFNP vs standard (p<0.046)
- 2.50 NIV vs HFNP (p<0.006)
Didn’t change Intubation rate but did change mortality at 90 days
Extubation to
BiPAP
Shown to decrease extubation failure,
in those that are high risk extubations.
Titrated vs
Uncontrolled O2
MI
Out of hospital cardiac arrest
COPD
Harm
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Circulation
Crystalloids
Which Crystalloid should we use for
Volume Resuscitation?
•
Normal Saline
•
Hartmans
•
Plasmalyte
Results
SPLIT Trial
Fluid therapy
(Plasmalyte vs Normal Saline)
JAMA last week! –
Multi-centre cluster RCT - NZ
n = 2278
SPLIT Trial - Outcomes
RIFLE AKI - 9.6% vs 9.2% (p=0.77)
Difference in Serum Creatinine - 0.21mg/dl vs 0.18mg/dl (NS)
RRT 3.3% vs 3.4%
MV 68.6% (15.3hrs) vs 67.7% (14.2hrs)
LoS ICU/ Hospital - 1.5/7.45 days vs 1.47/7.33 days
ICU/Hospital Mortality - 6.6%/7.6% vs 7.2%/8.6%
SPLIT Trial
Feasibility Study
Sample size and power
calculations not possible
Colloids
Albumin
vs
Starches
vs
Gelatine
vs
Blood
FEAST Trial
NEJM - 2011
Multi-center RCT - Africa
n = 3141
Albumin bolus vs N/S bolus vs Maintenance
Cumulative probability of death
48 hours
28 days
FEAST Trial
Study halted!
Could a fluid bolus really cause death?
But, lots of criticism in terms of generalisability
CHEST Study
Compared – Voluven vs N/S
7000 ICU Patients
Mortality - 18% vs 17%
LOS (ICU or Hospital)
RRT - 7% vs 5.8% (RR 1.21)
Pruritis / Rash / Hepatic Failure
Albumin
TBI
(SAFE trial – NEJM 2004)
Sepsis
(ALBiOS – NEJM 2014)
TBI
(SAFE trial - NEJM 2004)
Sepsis
(ALBiOS – NEJM 2014)
ALBiOS
Does 20% HAS vs Crystalloid alone reduce
28 day mortality in Severe Sepsis?
n = 1818 in 100 Italian ICUs
Intervention
300ml 20% HAS daily Albumin ≥30g/l
Crystalloid as clinically indicated
Median Fluid 3738ml vs 3825ml (p=0.1) for
first 7 days
ALBiOS
Outcomes = no change in mortality
Pragmatic Study
Low loss to Follow up (1.6%)
Open-Label study
Under-powered - 45% mortality used in power calc.
Protocol Violations?
37% in control received albumin
Violation of albumin admin in 42% of intervention group
?
?
X
Blood
Blood
Old vs New
(TRANSFUSE)
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Disability/Neuro
Cardiac Arrest
TTM
T 32-34 vs 36 C
Sedation
Nothing really new
Dexmedetomidine
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Exposure:
Temperature and
Sepsis
Fever and Sepsis
What has a worse prognosis?
• Sepsis and Fever
• Sepsis and Hypothermia
Results
Paracetamol in
Sepsis
HEAT Trial
Paracetamol vs Placebo in the Septic ICU Patient
NEJM (last week)
Multi-centre RCT - Australasia
n = 700
No difference in ICU free days or mortality
Early Goal Directed
Therapy in Sepsis
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Feeding, Fluid
Balance and Renal
Function
Feeding
Nothing new
Fluid Balance
If we give fluid, you gotta get it back at
some point
Renal
Function/Protection
Avoid nephrotoxics
‘Normal’ MAP – under investigation
Avoid dehydration
Unobstruct
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
GI and Abdomen
Nothing new
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Lab Tests
Dysnatraemia
Under investigation
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Lines
US guidance for lateral SC/Axillary vein
In plane
Out of plane
SC vs IJ vs Femoral
Checking for complications/position with
U/S
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Medications
Steroids in Sepsis
(ADRENAL study)
Vitamins and Hormone
Replacement
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
FASTHUG
Feeding
Analgesia – more Ketamine, less regional anaesthesia
Sedation
Thromboprophylaxis – Enoxaparin rather than Heparin (PROTECT)
Head up
Ulcer prophylaxis – if feeds established don’t need PPI
Giucose control – gentle control rather than tight (NICE)
Airway
Breathing
Circulation
Disability/Neuro
Exposure: Temperature and Sepsis
Feeding, Fluid balance, Renal Function
GI and Abdomen
Labs
Lines
Medications
FASTHUG
Family
Family
In the room during CPR
In the room during rounds (privacy)
Discharge planning and Handover critical
Geriatric ICU
Emerging Data
Very difficult to predict who is going to do well
The ability to predict the functional outcome
imperative
Take home
messages
(1)
ICU is developing in many
areas.
(2)
The resuscitation gear you use
in OT may be in the ICU.
(3)
Although we drink a lot of
coffee, we do have a lot of
outreach and research to do!
Thank you
Questions?
References
Most references
from
Life in the Fast Lane
Delayed Sequence Induction References
Löllgen RM, Webster P, Lei E, Weatherall A. Delayed sequence intubation for management of respiratory failure in a
6-year-old child in a paediatric emergency department. Emerg Med Australas. 2014 Jun;26(3):308-9. doi:
10.1111/1742-6723.12196. Epub 2014 Apr 8. PubMed PMID: 24712856.
Schneider ED, Weingart SD. A case of delayed sequence intubation in a pediatric patient with respiratory syncytial
virus. Ann Emerg Med. 2013 Sep;62(3):278-9. doi: 10.1016/j.annemergmed.2013.03.027. PubMed PMID: 23969131.
Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective
Observational Study. Ann Emerg Med. DOI:http://dx.doi.org/10.1016/j.annemergmed.2014.09.025
Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J
Emerg Med. 2011 Jun;40(6):661-7. Epub 2010 Apr 8. Review. PubMed PMID:20378297.
Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management.
Ann Emerg Med. 2012 Mar;59(3):165-75.e1. Epub 2011 Nov 3. Review. PubMed PMID:22050948.
Cricoid Pressure
Allman KG. The effect of cricoid pressure application on airway patency. J Clin Anesth. 1995 May;7(3):197-9. PubMed PMID: 7669308.
Bhatia N, Bhagat H, Sen I. Cricoid pressure: Where do we stand? J Anaesthesiol Clin Pharmacol. 2014 Jan;30(1):3-6. Review. PubMed PMID: 24574584; PubMed
Central PMCID: PMC3927288.
Bouvet L, Albert ML, Augris C, Boselli E, Ecochard R, Rabilloud M, Chassard D, Allaouchiche B. Real-time detection of gastric insufflation related to facemask pressurecontrolled ventilation using ultrasonography of the antrum and epigastric auscultation in nonparalyzed patients: a prospective, randomized, double-blind study.
Anesthesiology. 2014 Feb;120(2):326-34. doi: 10.1097/ALN.0000000000000094. PubMed PMID: 24317204.
Butler J, Sen A. Best evidence topic report. Cricoid pressure in emergency rapid sequence induction. Emerg Med J. 2005 Nov;22(11):815-6. Review. PubMed
PMID: 16244348; PubMed Central PMCID:PMC1726598.
Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007 Dec;50(6):65365. Epub 2007 Aug 3. Review. PubMed PMID: 17681642.
Harris T, Ellis DY, Foster L, Lockey D. Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to
rapid safe intubation? Resuscitation. 2010 Jul;81(7):810-6. doi: 10.1016/j.resuscitation.2010.02.023. Epub 2010 Apr 15. PubMed PMID: 20398995.
Landsman I. Cricoid pressure: indications and complications. Paediatr Anaesth. 2004 Jan;14(1):43-7. Review. PubMed PMID: 14717873.
MacG Palmer JH, Ball DR. The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetised patients. Anaesthesia. 2000
Mar;55(3):263-8. PubMed PMID:10671846.
Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anaesth. 2007 Sep;54(9):748-64. Review. PubMed
PMID: 17766743.
Ovassapian A, Salem MR. Sellick’s maneuver: to do or not do. Anesth Analg. 2009 Nov;109(5):1360-2. doi: 10.1213/ANE.0b013e3181b763c0. PubMed PMID: 19843769.
Priebe HJ. Use of cricoid pressure during rapid sequence induction: Facts and fiction. Trends Anaes Crit Care. 2 (2012) 123-127 [Free Full Text]
Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is
irrelevant. Anesth Analg. 2009 Nov;109(5):1546-52. PubMed PMID: 19843793. [Fulltext] (also see the comments linked to the fulltext article and the University of Wisconsin
video below)
Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet. 1961 Aug 19;2(7199):404-6.
PubMed PMID: 13749923.
Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance
imaging. Anesthesiology. 2003 Jul;99(1):60-4. PubMed PMID: 12826843.
Tournadre JP, Chassard D, Berrada KR, Boulétreau P. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology. 1997
Jan;86(1):7-9. PubMed PMID: 9009934. [Fulltext]
Vanner R. Cricoid pressure. Int J Obstet Anesth. 2009 Apr;18(2):103-5. doi: 10.1016/j.ijoa.2009.01.002. Epub 2009 Feb 23. PubMed
PMID: 19233640.
Zeidan AM, Salem MR, Mazoit JX, Abdullah MA, Ghattas T, Crystal GJ. The effectiveness of cricoid pressure for occluding the esophageal entrance
in anesthetized and paralyzed patients: an experimental and observational glidescope study. Anesth Analg. 2014 Mar;118(3):580-6. doi:
10.1213/ANE.0000000000000068. PubMed PMID: 24557105.
High Flow Nasal Oxygen
Frat J.-P., Thille A.W., Mercat A., et al. High Flow Oxygen through Nasal Cannula in Hypoxic Respiratory Failure N
Engl J Med 2015; 372:2185-2196 - June 4, 2015
Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure.
N Engl J Med. 2015;372:(23)2185-96. [pubmed]
Lee JH, Rehder KJ, Williford L, Cheifetz IM, Turner DA. Use of high flow nasal cannula in critically ill infants,
children, and adults: a critical review of the literature. Intensive Care Med. 2013 Feb;39(2):247-57. doi:
10.1007/s00134-012-2743-5. Epub 2012 Nov 10. PubMed PMID: 23143331.
Miguel-Montanes R, Hajage D, Messika J, et al. Use of high-flow nasal cannula oxygen therapy to prevent
desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med.
2015;43:(3)574-83. [pubmed]
Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological
method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70:(3)323-9. [pubmed]
Ricard JD. High flow nasal oxygen in acute respiratory failure. Minerva Anestesiol. 2012 Jul;78(7):836-41. Epub
2012 Apr 24. Review. PubMed PMID: 22531566. [Free Fulltext]
Ward JJ. High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care. 2013
Jan;58(1):98-122. doi: 10.4187/respcare.01941. Review. PubMed PMID: 23271822. [Free Full Text]
Nava, S., et al (2005) “Noninvasvie ventilation to prevent respiratory failure
after extubation in high risk patients” Crit Care Med 33:2465-2470
Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial
Infarction. Circulation. 2015; 131(24):2143-50. PMID 26002889
Abdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths
and facts. Crit Care. 2012 Oct 29;16(5):323. [Epub ahead of print]
PMID: 23106947 PMCID: PMC3682248
Hope, J. et al (2010) “Association Between Arterial Hyperoxia Following
Resuscitation From Cardiac Arrest and In-Hospital Mortality” JAMA 303(21):
2165-2171
• Nielsen N, et al for the TTM Trial Investigators. Targeted Temperature
Management at 33°C versus 36°C after Cardiac Arrest. November 17, 2013 DOI:
10.1056/NEJMoa1310519 [Free Full Text]