Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Updates in ICU Jeremy Fernando Intensivist and Anaesthetist Rockhampton Queensland My ICU Round A B C D E F G L L M F F 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]