This is an episode I recorded with Professor Stephen Brett, outgoing President of the Intensive Care Society at the State of the Art meeting 2016. During the conference, he had had a pro-con debate with Brian Cuthbertson who is Chief of the Department of Critical Care Medicine at Sunnybrook Health Sciences Centre and Professor in the Interdepartmental Division of Critical Care Medicine at the University of Toronto.

I think the outcome of the debate was very inconclusive other than to say that we need more evidence which may have to be collected in a more qualitative way. During this chat I think we arrive at the same conclusions too.

Some of the studies in the debate :

The PRaCTICaL study of Nurse led, intensive care follow-up programmes for improving long term outcomes from critical Illness.

A national survey of intensive care follow-up clinics

One year outcomes in caregivers of Critically Ill Patients

The Recover Trial

Improving outcomes after critical illness: harder than we thought!

Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis

Gavin and I try to peel apart the layers of the LeoPARDS Trial which assesses the benefits of levosimendan for the prevention of organ dysfunction in sepsis. It's another interesting study which actually asks more questions that it answers, but all questions we may try to answer one day with more research.

I am still hoping to get together with Danni Bear the dietician in the near future to talk about the latest findings from ASPEN. Watch this space.

A prospective randomised trial comparing insertion success rate and incidence of catheterisation-related complications for subclavian venous catheterisation using a thin-walled introducer needle or a catheter-over-needle technique

1. Kim, B. G. Kim, Y. J. Lim, Y. T. Jeon, J. W. Hwang, H. C. Kim, Y. H. Choi and H. P. Park

http://dx.doi.org/10.1111/anae.13543

Gavin Denton and I discuss this piece of research which tries to establish which needle is best for inserting the central venous catheter into the subclavian vein. The results seem fairly clear in this one. I for one am going to be sticking to my current practice.

Gavin also kindly broke down the research as a quick summary.

Clinical question.

In patient requiring central venous subclavian catheterisation, does a needle over catheter technique increase the success rate of catheterisation and reduce compilations compared to a needle wire approach.

Design.

• Two centre.
• Single blinded.
• Randomised (computer randomised).
• Assignment sealed until the day of surgery.
• Data collected by third party who was blinded to assignment.
• Power calculated on a 19% incidence of complications.
• 80% power calculation, a p value 0.05. N=188 per group, to identify 10% difference.
• 10% extra recruited to account for drop out (only two dropped out). N=214.

Setting.

Elective neurosurgery.

Population.

Elective patients in two South Korean hospitals.

Intervention/control.

• Right subclavian central venous catheterisation.
• Needle guide wire versus needle canula technique.
• Two anaesthetist in each hospital performed all canulations, and all had practiced at least 100 central venous canulations.
• Either landmark or ultrasound technique could be used.
• The landmark technique was clearly described.

Outcome.

• Primary outcome (catheter related complications). Needle-wire 5.8% vs 15.5% needle-catheter, p.value 0.001.
• First pass success. Needle-wire 35.4% vs 62% needle-catheter, p.value 0.001
• Overall canulation success, needle-wire 97% vs 92% needle-catheter, p.value 0.046.
• Haemotoma, needle-wire 3.8% vs 10.2% needle-catheter, p.value 0.012.
• Time to canulation, 122 seconds needle-wire vs 101 seconds needle-catheter, p.value 0.002.

Author’s conclusion.

Needle-catheter technique causes more complications compared to the needle-wire technique.

Strengths.

• Single blinded, double blinding would be impossible.
• Experience of clinicians.
• Minimum number of clinicians limit confounding.
• Well powered with minimal dropout.

Weaknesses.

• Low BMI in study patients, may limit generalisability to other populations.
• Elective population, may limit generalisability to patients of greater acuity.
• May be under powered to detect differences between techniques when ultrasound is used.
• Does not clearly state if patients were randomised to ultrasound.

Bottom line.

 The traditional teaching that needle-catheter central venous subclavian cannulation is easier and has less complications compared to a need wire technique is incorrect and is in fact inferior. Using medcalc and the available figures odds ratio for complications using the needle-catheter is 2.74, absolute risk increase of 8%, and a number needed to harm of 11 assuming a 95% confidence interval.

Links.

http://www.ncbi.nlm.nih.gov/pubmed/27396474

My good friend Dr. Nitin Arora and I had a discussion about the various combinations of drugs which can be used during a rapid sequence induction and the reasons for giving them. Sometimes its not always evident why the doctor wants the drugs he asks for. Hopefully, in this podcast, some of this can be cleared up.

I ran Nitin through his paces and presented him with three different scenarios in which different drugs might be required. He passed with flying colours!

LIFTL- Rapid Sequence Induction

Rapid Sequence Intubation: Medications, dosages, and recommendations

This episode is in conjunction with my friends over at JICScast Segun Olusanya and James Day. We met with Dr Anna Batchelor, Carole Boulanger and Gavin Denton to discuss the role of the Advanced Critical Care Practitioner, its impact on the service as a whole and what the future may look like for this growing body of health care workers.

I also go on to say that I am now moving to Warwick Hospital in my role as an Advanced Critical Care Practitioner, and leaving the Emergency Medicine Department behind. I have learned a vast amount whilst there but the Intensive Care Unit is where I feel most comfortable.

I have covered some aspects of PTSD already in CCP Podcast 041: PTSD in Critical Care when I chatted with Dorothy Wade about some of her research. This gave me great food for thought, so I went to read some of the plentiful research out there. I posted this recently but also decided to release my thoughts as a podcast for those of you who prefer to listen that way.

I hope you find it thought-provoking....

Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study.

This was a very enlightening discussion with Rosalind Elliott from Sydney about her study. Our poor ITU patients are struggling to get any decent sleep- what can we do to help them?

Rosalind Elliott qualified as a nurse in London, England in the early 90s and worked in intensive care for almost two decades. In 1998 she moved to Sydney. Roz completed her PhD studies with the University of Technology, Sydney, Australia in 2012. She conducted a research study, ‘Improving the quality and amount of sleep for the intensive care patient’. Previously during her Masters studies Roz investigated the effect of a sedation guideline on the duration of ventilation on intensive care patients. In addition to her strong research interest she is an advocate for nursing practices to improve patient comfort and quality of care. In her previous role as a Clinical Nurse Consultant in intensive care she published papers on the prevention of pressure ulcers and eye care in ICU patients.

The Insomnia Severity Index

Patient- Nurse Interrater Reliability and Agreement of the Richards-Campbell Sleep Questionnaire American Journal of Critical Care 2012

Non-pharmacological interventions for sleep promotion in the intensive care unit

Cochrane Database Syst Rev. 2015 Oct

It is well-known that patients in the intensive care units do suffer from a lack of sleep and frequent sleep disturbances.

This is a Cochrane review looking at the efficacy of nonpharmacological interventions for sleep promotion in the critically Ill adults in the intensive care units.

Perhaps one of the main results to come from this Cochrane review was the poor quality of the studies that they included. They initially included 30 trials, giving them a total of 1569 participants. However the quality was generally low or very low and as a consequence only three trials, those concerning earplugs or eye masks or both, provided data it suitable for two separate meta-analysis.

I would like in this podcast just to summarise some of the articles that they actually looked at when considering how to optimise the patient’s sleep in the intensive care unit and the various methods used.

Why Won't My Patient Sleep!

The Intensive Care patient will often lie awake at night, eyes wide open, clearly with no intention of sleeping. So why won't the intensive care patient sleep? Perhaps we need to understand what happens during normal sleep and take it from there.....

Stages of sleep

Sleep is divided into non-rapid eye movement and rapid eye movement phases. The non-rapid eye movement stage is further divided into three different stages. The third of these, stage N3, is significant for its role in restorative processes.

Rapid eye movement sleep occupies 20% to 25% of the total sleep period. The brain is highly active in this period is associated with dreaming.

The circadian rhythms which drive the sleep wake cycle is regulated by adenosine and melatonin. One helps us sleep the other helps us keep awake.

What happens during sleep?

During sleep there is a loss of compensatory responses, such as shivering and sweating. The body temperature reaches its lowest point during the latter part of sleep and then rises prior to awakening.

Voluntary control of respiration is lost during sleep. Moving from being awake to the early phases of sleep is marked by a reduction in minute volume. Due to relaxation of upper respiratory muscles, increased airway resistance, and diminished central respiratory drive hypoventilation can occur which will increase arterial PCO₂ levels.

During non-rapid eye movement sleep increased parasympathetic tone causes a decreased blood pressure, heart rate and systemic vascular resistance.

There is more variability during rapid eye movement sleep. There may be bursts of vagal activity and along with decreased sympathetic tone there may be bradyarrhythmias and sinus pauses.

Growth hormone and prolactin peak during sleep. Cortisol levels are also at their lowest level after sleep onset. Thyroid stimulating hormone is inhibited during sleep and will increase with sleep deprivation.

Sleep in ICU

Patients in intensive care commonly report poor sleep quality and surveys of survivors have shown that sleep deprivation ranks among the top three major sources of anxiety and stress during their stay in intensive care.

50% of their sleep will occur during daytime hours, and the average approximately 41 sleep periods per 24 hours each one lasting approximately 15 minutes. They commonly go through the first two stages of sleep without then moving onto the latter stage and rapid eye movement sleep. In other words they have broken light sleep without the restorative stages needed.

Causes of sleep disruption.

Noise- staff conversations, alarms, telephones and televisions are commonly quoted as being the causes of the noise within the intensive care unit. The recommendation is for maximum hospital noise levels of 45 dB during the day and 35 dB at night. Commonly however both daytime and night time noise levels routinely exceed 80 dB.

Patient care activities- patients in intensive care may experience 40 to 60 interruptions each night due to activities such as patient assessments, vital signs and is, equipment adjustment and medication administration to name a few.

Light- intensive care survivors have reported that light is less disruptive than noise and patient care activities. However it is known that nocturnal melatonin secretion in intensive care patients can be suppressed, causing further difficulties in sleeping.

Mechanical ventilation- the patient that is ventilated as compared to the patient that isn’t is more likely to suffer from sleep deprivation. This is due to factors such as increased ventilatory effort, abnormal gas exchange, and patient ventilator dysynchrony. Other factors may include endotracheal tube discomfort, ventilator alarms, suctioning, positioning, and frequent assessments.

Medications-some commonly used medications in intensive care can have profound effects on sleep quantity and quality. The sedation we use with many of the patients in intensive care is also disruptive to sleep. For example opiates such as fentanyl and morphine inhibit rapid eye movement sleep, profoundly suppress the latter stages of non-rapid eye movement sleep and can provoke awakening at night. Benzodiazepines and opiates are also associated with delirium in critically ill patients.

Propofol suppresses the latter stages of non rapid eye movement sleep whereas dexmedetomidine has been shown to enhance this stage of sleep in a rat model.

Psychological consequences of sleep deprivation in critically ill patients.

Delirium- delirium is associated with patient mortality, increase cost and length of stay and long-term cognitive impairment. It is possibly difficult to say whether sleep deprivation directly contributes to delirium but circadian rhythm disturbance, sedating medications and opiates contribute to both delirium and sleep disruption.

Psychiatric disturbances- survivors of critical illness often experience frightening flashbacks, nightmares, anxiety, and mood disturbances related to their intensive care stay.

Post-traumatic stress disorder has been shown in 10% to 39% of intensive care unit survivors during their first year after the intensive care unit stay. Post-traumatic stress disorder symptoms have been present in up to 45% of those discharged and is still present in 24% at 8 years after intensive care unit discharge.

Depression among survivors is also very common and has been shown to be present in 28% of patients within the first year of intensive care unit discharge. In those that suffered from ARDS the prevalence of depression is a size 46% at one year and 23% at two years after discharge.

Many studies have demonstrated depressive symptoms and increase levels of fatigue anxiety and stress in healthy participants undergoing total or partial sleep restriction. Sleep disruptions in the critically ill patient may be contributing to post intensive care unit psychiatric disorders. This is possibly not that well understood at the moment.

Cognitive dysfunction-impairment of memory, attention, concentration, language, mental processing speed, visuospatial abilities and executive function have all been shown to have been affected following critical illness. Some of the causes are thought to include delirium and sedating medications.

Due to neuro cognitive dysfunction many intensive care unit survivors experience challenges with daily functioning, social isolation and difficulties returning to work.

Quality of life-health-related quality-of-life concerns one’s perception of overall well-being and incorporates measures of physical, mental, emotional, and social functioning. Critical illness is associated with long-term impairments in quality of life for many years after intensive care unit discharge chronically reduce sleep also leads to reductions in quality of life.

With all of this in mind it would seem important therefore to try to promote whatever we can to help the patient to sleep whilst in the vertical care department. How can we do this? What measures can we take? Do you already take measures in your department? If you do, how are you sure they make any difference?

How high should I sit my patient?

I was lucky enough to be able to chat to Louise Rose again. She and I first had a conversation back on CCP Podcast 013: Mind and Body. In this episode we talk about a study she was involved in, which looked at the use of meters to measure the angle of the bed when nursing the ITU patient. We also go onto discuss whether it matters if we do this at thirty degrees or forty five degrees.

The use of bed-dials to maintain recumbent positioning for critically ill mechanically ventilated patients (The RECUMBENT study): Multicentre before and after observational study.

We also go on to chat about some of the issues with mobilising the critical care patient at a much earlier stage than perhaps most of us do currently. This is an issue I discussed with Carol Hodgson in CCP Podcast 039: Early Mobilisation- Get Them Moving! It is becoming a subject close to my heart and one that I think I may investigate further in the future.

The Intensive Care Society have now released ALL of their presentations as podcasts for you to listen to for FREE. This is fabulous and I strongly recommend that you go over to their website to have a look. The conference was great and I hope you will consider trying to get there next year.

The Content on the website is provided for FREE as is the

podcast.