Tc ed wrap up
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The document summarizes key findings from 3 large studies presented at an International Symposium on Intensive Care and Emergency Medicine: 1) The ProMISe trial found that early goal-directed therapy (EGDT) for septic shock did not reduce mortality compared to usual care and increased resource usage. 2) The ABLE trial found no difference in mortality or other outcomes when comparing transfusion of fresh red blood cells versus standard-issue red cells in critically ill patients. 3) A study of over 1 million patients found that the SIRS criteria for identifying sepsis excluded about 12% of patients with infection and organ failure, calling into question the utility of the SIRS criteria.
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Tc ed wrap up
- 1. TC’s Wrap Up A potpourri of the blogosphere, grand rounds and interesting stuff 30/4/2015
- 2. International Symposium on Intensive Care and Emergency Medicine Update • 3 big studies – ProMISe – ABLE – SIRS Criteria in Sepsis 2
- 3. ProMISe • In a pragmatic, open, parallel group, randomized controlled trial, Mouncey and colleagues compared an early goal-directed therapy protocol for the first six hours of management (n=630) with usual care (n=630), in 1260 patients with early septic shock across 56 English hospitals
- 4. ProMISe • EGDT – A central venous catheter capable of continuous SCVO2 measurement (Edwards Lifesciences Ltd) Controversial and arterial line was inserted – A treatment algorithm was commenced based on Rivers' original EGDT algorithm & included: • Supplemental oxygen if not already initiated and titrated to achieve SpO2 > 93% • 500mls bolus of crystalloid or colloid at least every 30 minutes until CVP > 8mmHg • Vasopressors to achieve MAP of > 65 and/or SBP > 90mmHg • SCVO2 >70% once CVP and MAP targets achieved – If SCVO2 < 70% and Hb < 100g/dl → packed red cells – If SCVO2 < 70% and Hb > 100g/dl → dobutamine 2.5–20mcg/kg/min – If SCVO2 still < 70% → increase oxygen → NIV → Mechanical ventilation » Sedative and paralysing agents used if mechanically ventilated • Treatment algorithm continued for 6 hours. At the end of six hours, the patient returns to standard care and continuous SCVO2 monitoring was no longer mandated.
- 5. 5 Dodgy
- 6. ProMISe • Control • Usual Care – Arterial line and a CVC may be inserted if considered clinically appropriate – SCVO2 measurement was not permitted during the 6 hour intervention period – Decisions about the location of care delivery, investigations, monitoring, and all treatments were made at the discretion of the treating clinician
- 7. ProMISe • Comparing EGDT vs usual care interventions • Insertion of central venous catheter: 92.1% vs. 50.9% • Arterial line insertion: 74.2% vs. 62.2% • Vasopressor use: 53.3% vs 46.6% • Dobutamine use: 18.1% vs 3.8% • Red cell transfusion: 8.8% vs 3.8% • Advanced respiratory support: 28.9% vs 28.5% • ICU admission: 88.2% vs 74.6%
- 8. ProMISe • EGDT vs UC – No difference in 90 day mortality (29.5%vs29.2%) – Worsened organ failure with EGDT – Increased resource usage with EGDT • Vasoactive drugs, red cell transfusions, advanced circulatory support, LOS in ICU – No benefit seen for EGDT was seen in any subgroup – No difference in adverse events
- 9. ABLE • In a parallel group, blinded, randomized controlled trial, Lacroix and colleagues compared transfusion of fresh red cells (stored for < 8 days, n=1211) with standard-issue red cells (the oldest compatible units available in the blood bank, n=1219) in 2,400 critically ill
- 10. ABLE • No difference in 90 day mortality • No significant differences in any secondary outcome – Death, LOS, transfusion reactions
- 11. SIRS Criteria in Sepsis • Kaukonen and colleagues tested the utility of the SIRS criteria for the identification of severe sepsis using data from 1,171,797 patients, of whom 109,663 had infection and organ failure, over a 14 year period (2000 to 2013) from 172 ICUs in New Zealand and Australia
- 12. SIRS Criteria in Sepsis • SIRS criteria – 1. Body temperature >38°C or <36°C – 2. Heart rate >90/minute – 3. Respiratory rate >20/minute or PaCO2 lower than 32mmHg (4.3kPa) – 4. White blood cell count >12000/μL (>12x109/L) or <4000/μL (<4x109/L) • When 2 or more criteria are present
- 13. SIRS Criteria in Sepsis • Percentage breakdown – SIRS-positive severe sepsis: 87.9% (n=96,385) – SIRS-negative severe sepsis: 12.1% (n=13,278) • patients with SIRS-positive severe sepsis were – younger • 65.8 vs 68.3; p<0.001 – more severely ill • APACHE III score – 73.7±30.1 vs 56.7±26.1; p<0.001 – suffered higher mortality • 24.5% vs 16.1%; p<0.001 – suffered greater organ failure • septic shock – 58% vs 42.2%; p<0.001 • acute renal failure – 18.9% vs 11.7%; p<0.001 – reduced rates of • mechanical ventilation – 53.3% vs 55.2%; p<0.001
- 14. SIRS Criteria in Sepsis • both groups had decreasing mortality over this time period – SIRS-positive group: • from 36.1% to 18.3%, p<0.001 – SIRS-negative group: • from 27.7% to 9.3%, p<0.001 • adjusted mortality increased linearly with each additional SIRS criterion – odds ratio for each additional criterion 1.13 (95% CI 1.11 to 1.15; P<0.001) – without any transitional increase in risk at a threshold of two SIRS criteria
- 15. SIRS Criteria in Sepsis • The authors concluded – "The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality, and failed to define a transition point in the risk of death."
- 16. SIRS Criteria in Sepsis • The traditional SIRS-criteria definition of severe sepsis, previously thought to have at least sensitivity at expense of specificity will miss 1 in 8 patients with organ failure and an underlying infection. • Considering only approximately 1/3rd of patients with two or more SIRS criteria in the Emergency Department have an underlying infection, the utility of these criteria is substantially less reliable than previously thought. • Code Sepsis anyone?
- 17. Thrombolysis in acute ischaemic stroke: time for a rethink? • BMJ March 2015 • Use of alteplase 3-4.5 hours after stroke is supported by guidelines and meta-analyses based on analyses that do not directly examine treatment in this time frame • Direct comparisons of alteplase with no alteplase at 3- 4.5 hours after stroke suggest an absolute increase in mortality of 2% and no clear benefit • Recommendations to use alteplase 3-4.5 hours after stroke should be re-evaluated I want a copy of the consent the neurologists use before thrombolysis
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- 22. Chronic Digoxin Toxicity • Normal range can be anywhere from 0.5- 2.0ug/L • Risk of CDT is derived from level plus signs and symptoms • How much Digibind? • Number of vials=Dig level x weight/100
- 23. Or 2 vials 23
- 24. Gas
- 25. RTA Type Type 1 Type 2 Type 4 Location Distal tubules Proximal tubules Adrenal Acidosis? Yes (severe) Yes Mild if at all Potassium Pathophysiology Failure of H+ secretion by the α intercalated cells and reclaim K Failed HCO3 − reabsorption from the urine by the proximal tubular cells Deficiency of aldosterone, or a resistance to its effects, (hypoaldosteronism, pseudohypoaldoster onism)
- 26. Mr S • K+ is 7.8 • Urine pH 5.03 – RTA type 1 cannot acidify urine below pH 5.3 • On ACEi and spironolactone
- 27. RCL • Residential Care Line • Like HITH but for people in an aged care facility • Has a NP • Can deal with UTIs, constipation, dementia MX, etc 27
- 28. Dihydrofolate reductase inhibitors • Methotrexate • RA, Crohn’s, psoriasis, etc • Trimethoprim +/- sulfamethoxazole • Infections - UTI, prevent PCP, etc. • High potential for concurrent use in patients 28
- 29. • Why such a disparity in uses? • Mammalian vs bacterial dihydrofolate reductase inhibitors • Potential for lethal interaction - through pancytopenia causing overwhelming sepsis 29
- 30. Tibial nerve block • Most of sole of foot supplied by tibial nerve • relatively easy and effective nerve block • poor success rates without USS • Volunteer? 30
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- 35. You don’t need the K-Hole • 0.3mg/kg of ketamine (sub-dissociative dose) shows comparable efficacy and safety to IV morphine • For opioid resistant/tolerant pain 35
- 36. 36 Here is the video link: http://emcrit.org/wee/real-surgical-airway/
- 38. Not Anne Frank’s sister • Jacques Lisfranc de St. Martin • 1829-1893 • French SurgeonSurgeon in Napoleon’s army who described an amputation method through the tarsometatarsal joints 38
- 39. 50% sensitivity non-WB XRs • Lisfranc injury refers to disruption of the tarsometatarsal joint. Injuries range from sprain (minor diastasis) through to tarsometatarsal fracture-dislocation.The presence of small avulsed fragments (fleck sign) are further indications of ligamentous injury and probable joint disruption • Examples of this type of trauma include a rider falling from a horse but the foot remaining trapped in the stirrup, or a person falling forward after stepping into a storm drain. • low threshold to CT 39
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- 43. Fatties • The “Obesity” Paradox • There is evidence that obese patients have equal or even a reduced mortality compared to non-obese cohorts • Theories to explain the obesity paradox • Increased nutritional reserves (e.g. adipose tissue) that may deal with inflammation and metabolic stress • Patients may receive more aggressive care than their normal weight cohorts • The severely obese may be a younger cohort of patients and may skew the data • Sample size of critically ill obese patients still too small to conclude from studies • Obese patients may have increased: • duration of intubation and mechanical ventilation • longer length of ICU stay 43
- 44. Señor Chunkos • Inaccuracies in assessing blood pressure secondary to improper cuff size • A small bladder cuff may overestimate blood pressure by up to 50 mmHg • Appropriate bladder length should be at least 75% of upper arm circumference and a width greater than 50% the length of the upper arm • Difficulty in obtaining peripheral intravenous access even with ultrasound assistance • Difficulty in obtaining or interpreting diagnostic imaging • Limitations of ultrasound • Underpenetrated X-rays • Weight limits of CT/MRI machines • Appropriate and therapeutic dosing of medications is challenging • Larger volume of distribution for lipophilic drugs • Increased clearance of hydrophilic drugs • Reduction in lean body mass and tissue water • An overall understanding that drugs differ by the way they should be dosed • Ideal body weight? • Total body weight? • Dosing weight? • Consider using clinical pharmacologists when you have them either available in person or by phone • Procedures can be difficult and increased risks of complications. Examples: • Endotracheal intubation • Central line placement • Thoracostomy 44
- 45. Chunky Monkeys • Differences in airway anatomy in the critically ill obese patient • Attempts at intubation are more challenging and have an increased risk of failure • Increased oropharyngeal tissue / Mallampati (III-IV) • Small oral opening • Limited neck flexibility • Increased neck circumference • Pulmonary changes in the critically ill obese patient • Restrictive physiologic pattern secondary to a reduction in chest wall compliance • Increased adipose tissue surrounding chest wall, diaphragm, and abdomen • Increased pressure on anterior chest from adipose tissue • Increased airway resistance • Para-pharyngeal fat deposition • Fibrosis from chronic airways changes • Repetitive opening and closing of small airways • Respiratory muscles endure an increased workload and oxygen consumption • Reduction in lung volumes • Total Lung Capacity • Functional residual capacity • Vital Capacity • Expiratory reserve volume • Intrapulmonary shunting • V/Q mismatch • All of the above changes may lead to severe hypoxemia, hypercarbia, and rapid desaturation during intubation 45
- 46. Tubbies •All of the above changes may lead to severe hypoxemia, hypercarbia, and rapid desaturation during intubation •Plan ahead! 46
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