Jonny Wilkinson (@wilkinsonjonny) and Dave Lyness (@Gas_Craic) were not at the Intensive Care Society State of the Art in person but both followed very closely via social media. Jonny has summarised a lot of the key points on his website Critical Care Northampton and in this podcast, we all discuss some of the issues raised. I would also recommend visiting Daves site at Propofology.com.

Interview Questions for Advanced Critical Care Practitioners

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My friend and colleague Dr Nitin Arora (@aroradrn) has just completed his Focussed Intensive Care Echocardiography (FICE) course and has managed to complete the 50 required scans in 63 days! It can be done. Segun (@iceman_ex) and I chat with him about his experience.

Interview Questions for Advanced Critical Care Practitioners

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NOT The Two Ronnies...but The Two Jonnys....and Twitter!

This is the third episode of an exciting new podcast project with Jonny Wilkinson (@WilkinsonJonny) who is an anaesthetist and Intensive Care Consultant at Northampton hospital He has a website, Critical Care Northampton, from where he does regular reviews of some of the many issues one can find on Twitter.

If this podcast does not convince you of the merits of Twitter then nothing will.

This is a discussion which follows on from CCP Podcast 077: NCEPOD 2017 Acute Non-Invasive Ventilation: Inspiring Change. In this episode, I have a chat about the NCEPOD findings with one of the authors, Mark Juniper and with Vicky Mummery a physio who is very involved in improving practice at her trust.

I think this discussion adds a lot to the last podcast and well worth a listen.

I think this might be one of the most important podcasts I have ever done along with the next in the series. This is the first of two podcasts covering the latest NCEPOD paper on Non-Invasive Ventilation. This can also be found on the NCEPOD web page, but they also kindly agreed to allow me to release it as a podcast for those of you who want to listen to it on the go. Once you have heard this one go to the next podcast 077 where I chat to Dr Mark Juniper one of the leads of the paper and Vicky Mummery a physiotherapist involved in quality improvement on this very subject.

Interview Questions for Advanced Critical Care Practitioners

NOT The Two Ronnies…but The Two Jonnys….and Twitter!

This is an exciting new podcast project with Jonny Wilkinson (@WilkinsonJonny) who is an anaesthetist and Intensive Care Consultant at Northampton hospital He has a website, Critical Care Northampton, from where he does regular reviews of some of the many issues one can find on Twitter. During this podcast, we discuss more POCUS stuff, AEDs and TOE amongst other things. I certainly learned a few new things.

If this podcast does not convince you of the merits of Twitter then nothing will.

Interview Questions for Advanced Critical Care Practitioners

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

You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.

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This is a conversation I had with Martin Horton (@chuckyhorton), Aimee Wright (@AimsleyW) and Ashleigh Lowther (@ashleighlowther) about an ACP conference they are planning on the 6th October 2017 at Birmingham City Football Club. The agenda looks great and it will also be a fabulous networking opportunity. Its also very reasonably priced!

Go here to book your place! See you there.

Interview Questions for Advanced Critical Care Practitioners

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

You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.

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Simon Hayward (aka @sonophysio) is a great advocate of lung ultrasound in the critical care patient. He currently is running a very popular course with one of his medical colleagues to help introduce people to this technique. He is busy! We talk about the reasons for doing so as well as discussing the recent conference he went to in South Africa for all kinds of therapists. 

He heard some interesting stuff out there so go listen and find out more.

I was lucky enough to be invited to the Home Mechanical Ventilation Conference in June 2017 by Rachael Moses (@rachaelmoses) and Professor Nick Hart (@NickHartThorax) and this is one of the presentations I thought you might like to hear. Bariatric surgery has become almost routine now and Andrew Jenkinson tells us why. Diets will never seem the same again after hearing this!

Interview Questions for Advanced Critical Care Practitioners

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NOT The Two Ronnies...but The Two Jonnys....and Twitter!

This is the fourth episode of an exciting new podcast project with Jonny Wilkinson (@WilkinsonJonny) who is an anaesthetist and Intensive Care Consultant at Northampton hospital He has a website, Critical Care Northampton, from where he does regular reviews of some of the many issues one can find on Twitter.

If this podcast does not convince you of the merits of Twitter then nothing will.

Interview Questions for Advanced Critical Care Practitioners

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

You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.

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Simple- My take of DasSMACC Day 3!

Interview Questions for Advanced Critical Care Practitioners

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Simple...DasSMACC Day 1- me summarising what happened. Great day-fabulous networking.

Interview Questions for Advanced Critical Care Practitioners

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

You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.

Thank you.

Amazon Link

NOT The Two Ronnies...but The Two Jonnys....and Twitter!

This is the third episode of an exciting new podcast project with Jonny Wilkinson (@WilkinsonJonny) who is an anaesthetist and Intensive Care Consultant at Northampton hospital He has a website, Critical Care Northampton, from where he does regular reviews of some of the many issues one can find on Twitter.

If this podcast does not convince you of the merits of Twitter then nothing will.

The three boys get together again to talk about the papers of the month.

 

A Multicenter, Randomized Trial of Ramped Position versus Sniffing Position during Endotracheal Intubation of Critically Ill Adults

Semler et al, 2017.

 

Clinical question.

In critically ill adults requiring endotracheal intubation, does the ramped position increase the lowest oxygen saturation during rapid sequence induction compared to the supine sniffing position.

 

Design.

• Multi-centre study involving four tertiary hospitals.
• Randomisation in a 1:1 ratio using computer generated blocks, seal envelopes assigned treatment groups and were opened on decision to enrol in the study.
• All patients were simultaneously enrolled in a second study involving the use of intubation checklists.
• 80% power to detect a 5% difference in the lowest oxygen saturation level with an alpha level of 0.05, 260 participants required, 260 patients enrolled on an intention to treat basis.

 

Setting.

Patients in critical care.

Conducted in the United States of America.

 

Population.

• 60% were intubated for hypoxia.
• Exclusions were intubation during cardiac arrest, patients requiring cervical spine precautions, and patients requiring urgent intubation. Patients were also excluded if clinicians thought a specific position was required for the procedure to be safely performed.
• All patients received sedation and neuromuscular blockade.
• BMI and use of video laryngoscopy were similar.

 

Intervention/control.

• Ramped position was defined as 25 degrees head up, the occiput was positioned over the end of the mattress, face parallel to the ceiling, sniffing position/ear to sternal notch was achieved using additional pillows or blankets.
• The sniffing position was achieved by placing pillows or blankets under the head to flex the neck forward of the torso and then extension of the neck. Patients were kept supine and pillows under shoulders were not allowed.
• There was no control over the pre-oxygenation position, position was at the operators discretion until the point of induction when the patient had to be positioned according to the assigned treatment arm.

 

Outcome.

• Primary outcome was the lowest oxygen saturation between induction and two minutes after successful intubation. There was no difference (p value 0.027) between the lowest oxygen saturation in either group.

 

• Secondary outcomes;
• First pass success 4% in the supine group vs 76.2% in the ramped group (not statistically significant, and not powered for this outcome P value .02). The glottic view obtained was worse in the ramped group.
• A trend towards improved oxygenation in the more severely hypoxic patients, but not powered to look at this subgroup.

 

Author’s conclusion.

The ramped portion does not appear to improve oxygenation during intubation and may result in a worse glottic view and lower the first pass success.

 

Strengths.

• Possibly the first randomised study on intubation position in a critically ill population.
• Multi-centre study.
• Sub-group analysis of operator experience did not have any impact on the results.

 

Weaknesses.

• Non-blinded study, however blinding impossible in this context.
• The study does not inform us on the optimal position to pre-oxygenate.
• Type of laryngoscope was not controlled, but blade type was similar between groups.
• Pre-oxygenaion position is not controlled for and may confound results.
• It is not clear if the use of a checklists in the parallel study could have confounded the data from this study.
• 53% of patients were ventilated through their apnea, this may also confound the data in regard to patients that were apneic throughout the intubation process.
• There were 46 exclusions, around 20 were in extremis and it is unknown whether there may have been benefit of ramped position in these cases. I suspect these cases may have been electively intubated head up.

 

Bottom line.

This study did not demonstrate a benefit in oxygenation during RSI in the ramped position over the supine position and worsened glottic view and first pass success.

 

 

Links.

 

https://www.ncbi.nlm.nih.gov/pubmed/28487139

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This is an important update from Carole Boulanger and Dr Simon Gardener at the 5th NAACCP conference in London 2017 about some of the changes anticipated for the ACCP body and how they hope the future will pan out. It is only short but full of lots of useful, and very encouraging information.

Interview Questions for Advanced Critical Care Practitioners

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

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Thank you.

NOT The Two Ronnies...but The Two Jonnys....and Twitter!

This is the second episode of an exciting new podcast project with Jonny Wilkinson (@WilkinsonJonny) who is an anaesthetist and Intensive Care Consultant at Northampton hospital He has a website, Critical Care Northampton, from where he does regular reviews of some of the many issues one can find on Twitter. 

If this podcast does not convince you of the merits of Twitter then nothing will.

Interview Questions for Advanced Critical Care Practitioners

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

You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.

Thank you.

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I was lucky to be asked to give a presentation about the role and the training of the Advanced Critical Care Practitioner at the 14th Critical Care Symposium in Manchester this year. This is the audio from that meeting as a podcast and I have also linked to the video with audio and slides combines. Hope you find it useful.

Another look at some of the recent Papers of the Month to catch our eyes. This time Gavin (@DentonGavin) and I look at two papers, one focussing on the use of Ultrasound with central lines and the other a study in African children and the possibility of heart failure being caused by fluids.

 

Myocardial and haemodynamic responses to two fluid regimens in African children with severe malnutrition and hypovolaemic shock (AFRIM study)

The WHO guidelines recommend that fluids are reserved only for those presenting with advanced shock and the use of low volume hypotonic solutions- the malnourished heart is at risk of biventricular failure so unable to respond to isotonic fluid challenges.

In two previous trials, there had been no evidence of heart failure caused by fluids and Ringers Lactate had been shown to be superior in shock reversal and with a lower mortality compared to 5% dextrose.

Previously in the FEAST trial, there had been increased mortality in the fluid bolus arm. However, children with gastroenteritis were excluded from the study. It has also been shown in Kenyan children with severe malnutrition that 50% presented with severe diarrhoea and there was an overall 20% mortality rate amongst this group.

Aim of Study

To examine myocardial function and hemodynamic response to fluid resus in hypovolaemic shock due to gastroenteritis.

Inclusion

• Children 6-60 months
• Clinical signs of severe malnutrition (using standard scoring system)
• Acute Hypovolaemic diarrhoea
• Signs of severe dehydration
• Shock
  • 2 of 3
    • CRT equal to or greater than 3
    • Temperature gradient
    • rapid and weak pulse volume.

Study Procedure

2 groups- bolus group (1) and rehydration group (2).

Group one received a bolus of 15ml/kg of RL over one hour which was then repeated once if shock signs persist. They were then given half strength Darrows/5% Dextrose at 4ml/kg/hr.

Group 2 received 10ml/kg/hr of RL over five hours.

Both groups were switched to oral hydration once they could tolerate it. Blood was given if their Hb was less than 5 or the shock was unresponsive to crystalloid at 10ml/kg over 3 hours.

Blood was taken including TNI and BNP as were vitals, echo and ECG.

A total of 20 patients recruited- 11 in group 1 and 9 in group 2.

Interventions

Group 1- 9/11 (82%) received 2 boluses and 4 received blood.

Group 2- 3/9 received 10ml/kg/hr RL followed by blood transfusion. Four patients substantially improved after 3 hours of intravenous rehydration and two died whilst receiving rehydration.

Results and Discussion

Neither clinical signs nor echo indicated evidence of fluid overload leading to adverse outcome when using boluses.

WHO recommends hypotonic solutions given slowly to prevent heart failure and sodium overload.

Major risk is those with the Kwashiorkor phenotype:

• Deficiency in dietary protein.
• Characterised by oedema, enlarged fatty liver and distended abdomen.

There was no evidence of gross myocardial dysfunction. Trop I levels was low in both groups- therefore not supporting the hypothesis that perturbations of cardiac function are secondary to heart failure.

In the majority of patients, myocardial and haemodynamic functional response to fluid administration led to initial improvement in the stroke volume index.

High SVRI observed in both groups- this reduced briefly after fluid admin but then returned to supranormal levels and they had persistently high levels of BNP- pointing towards heart failure. This is not supported in this study as being the mechanism.

Neither baseline measurements, nor haemodynamic response to fluid resuscitation supports the contention of compromised function indicative of heart failure overloading secondary to isotonic IV fluid or rehydration in African children with severe malnutrition.

Ultrasound as a Screening Tool for Central Venous Catheter Positioning and Exclusion of Pneumothorax. Critical Care Medicine 2017. Amir R, Knio ZO, Mahmood F, et al.

Clinical Question

In patients requiring central venous catheter placement, does the use of ultrasound compared with chest X-ray, confirm catheter position and identify pneumothorax?

Design.

Single centre study in the United States of America.

Non-inferiority study.

Prospective observational, non-randomised.

It’s really a validation study.

132 patients were required for a 90% power to detect a 20% difference in success rates.

Setting

Central line insertions in the intensive care unit or the theatre environment.

Population

Adult patients requiring central venous catheter placement in the jugular or subclavian vein.

Inclusion criteria:

Patients received the insertion as part of operating room, surgical or trauma care.

 

Exclusion criteria:

Patients where adequate ultrasound views could not be obtained due to oedema, obesity, abdominal or thoracic wounds, intra-cardiac catheters or wires.
Intervention:

All lines were inserted under ultrasound guidance, including needle visualisation and confirmation of the guide wire in the target vein. Wire position was then confirmed in the superior venacava-right atrial junction using a sub-costal or four chamber view with transthoracic echo before insertions of the catheter. Catheter tip position was then confirmed using the same views and looking for a swirl sign after rapid injection of agitated saline. Ultrasound assessment for pneumothorax used M-mode and the absences/presence of the sea-shore sign to exclude pneumothorax.

 

Control:

All patients then received a chest X-ray following insertion and the ultrasound based position confirmation.

Outcome

Primary outcome:

Difference in success rates in confirmation of position. ??? difficult to decipher what this means.

137 patients studied, adequate cardiac views were attained in 124 cases, in 98% of these cases, cardiac ultrasound was able to confirm the catheter tip position. There was a 1.7% absolute difference between cardiac echo and chest X-ray in ability to confirm catheter tip position.

Both X-ray and ultrasound ruled out pneumothorax in 124 cases where both tests were applied.
Authors’ Conclusions

Ultrasound, in the majority of patients, except where inadequate echo views are obtained can replace the use of chest X-ray in the confirmation of catheter position. The presence of lung sliding on ultrasound can reliably replace the use of chest X-ray to rule out pneumothorax.

Strengths

Lung ultrasound and cardiac echo skills are not universal in critical care, limiting generalisability.

In this study wire and catheter confirmation were done with ultrasound during the insertion process. Is this practical with a single sterile operator?

 

Weaknesses

The lack of control group may have obscured the possible complication rate where ultrasound is not used to confirm catheter tip position.

The absence of any pneumothoracies in these insertions makes it impossible to assert the sensitivity of ultrasound for detecting pneumothoracies.

There were very few subclavian catheter insertions.

The Bottom Line.

The use of ultrasound can be used to replace the chest X-ray to confirm catheter tip position and rule out pneumothoraces for the insertion of central venous catheters.

 

URL link http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=28422778&retmode=ref&cmd=prlinks

DOI: 10.1097/CCM.0000000000002451

Interview Questions for Advanced Critical Care Practitioners

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Myself and Jonny Wilkinson, an Intensivist from Northampton in the UK discuss some of the key topics to have passed by our Twitter streams over the last few days. This ranges from Sepsis to POCUS and a new use for Aspirin.

Many key sites are highlighted and these can be found in Jonnys fabulous website.

We are hoping that this is something we can do on a regular basis.

This is a discussion I had with Liz Staveacre (@lizzys39) who is Senior Critical Care Outreach Clinical Nurse Specialist at Northwick Park Hospital. Her Masters' dissertation looked at the factors that influence whether nurses will escalate the patient when it is necessary. From the discussion, it would seem that there is still some work to be done.

It certainly gives us some food for thought and hopefully will provide some refocus on the important problems.

Three more papers of the month for us to peruse. This time Gavin (@DentonGavin) and I are also joined by Sean Munnelly (@seanmunn).

The CLASSIC trial.

Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Hjortrup et al.  Intensive Care Med. 2016 Nov;42(11):1695-1705. Epub 2016 Sep 30. https://doi.org/10.1007/s00134-016-4500-7

Clinical Question.

In patient with septic shock, does the use of a restrictive approach to fluid resuscitation compared to a liberal approach, reduce the resuscitation fluid volume received.

Design.

• Randomised controlled trial carried out between 2014-2015.
• Multi-centre, multi-national trial.
• Computer allocation, with web-based, centralised
• randomisation system.
• 1:1 allocation
• Non-blinded to clinicians, allocation blinded to statistician.
• 150 patients were required to provide 80% power to detect 1.7L difference in the volume of resuscitation fluid administered. n=151 enrolled.

Setting.

• Scandinavian intensive care units in Denmark and Finland.
• 9 intensive care units.

Population.

• Adults over 18 years in intensive care.

Inclusion criteria:

• Sepsis as defined by the surviving sepsis campaign SIRS criteria.
• HR <140, systolic <90, lactate more >4 or need for vasopressors for less than 12hs preceding ITU admission.
• Patients must have received at least 30ml/Kg fluid resuscitation and ongoing need for vasopressor infusion.
• Use of colloid was not allowed.
• Resuscitation fluid could be Ringer's lactate or 0.9% saline.

Intervention.

• 250-500ml of crystalloid boluses were administered for 4 signs of severe hypo-perfusion, lactate >4, MAP <50 despite increases in noradrenaline, skin mottling above the knee cap or mottling score >2,  oligurea (but only for the first 2hrs after randomisation).
• Repeated boluses could be given depending on the response to the 4 criteria.
• A fluid bolus was not mandated for any of the 4 criteria.

Control.

• The control group could receive fluid boluses of crystaloid based on dynamic or static haemodynamic measures as long as variables improved.

Outcome.

• A co-primary outcome of: the volume of resuscitation fluid given for circulatory impairment in the first 5 days following randomisation and the volume of resuscitation fluid given for the duration of the intensive care stay.
• Secondary outcomes included the TOTAL fluid volume received in the first 5 days following randomisation and the duration of the ITU stay.

Primary outcome:

• There was a significantly significant fluid resuscitation volume difference in the first 5 days, 1.2L p= 0.001.
• There was a 1.4L total fluid resuscitation volume difference over the course of the intensive care stay p=0.001.

Secondary outcomes:

• In terms of the total fluid volume received, there was only a difference of 500ml over the course of the ITU stay, this was not statistically significant p=0.6.
• Further exploratory data provided, non-showed a statistically significant difference.

Authors’ Conclusions:

• It is feasible to conduct a trial that restricts fluid resuscitation volume in patients with septic shock.

Strengths.

• Randomised multi-centre trial.
• Separation of volume between patients, although it is not clear if this is meaningful

Weaknesses.

• Un-blinded, but not really feasible in this context.
• Primary outcome not patient centered.
• 36% of the intervention group had protocol violations, high lighting that it is difficult to stop clinicians wanting to give fluid. This may restrict the feasibility of conducting a meaningful trial.
• The total fluid volume difference between groups was only 500ml. This may meaning fluid restriction of resuscitation volumes may be circumvented by administration of maintenance fluids.

The Bottom Line.

 

• This study demonstrates that it is difficult to restrict clinicians from violating research protocols where the intervention is to restrict fluid resuscitation.

 

 Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Post operative Pulmonary Complications   

Is there any extra benefit to applying more intensive alveolar recruitment strategies for high-risk surgical patients already receiving perioperative small tidal volumes and protective lung ventilation?

Design: Randomised Clinical Trial

Setting: Single Center RCT performed at the Heart Institute from the University of Sao Paulo Brazil

Population: Patients aged 18-80-- undergoing elective CABG or cardiac valve surgery were assessed for elegibility ----  had hypoxemia as defined P:F ratio as 250mmHg

Inclusion criteria: Immediate postoperative period of myocardial revascularization and/or heart valve surgery (aortic and/or mitral)  • Age > 18 years and < 80 years • No previous pulmonary disease • Left ventricular ejection fraction > 35% • Body mass index < 40 kg/m2 • Oxygen index (PaO2/FiO2) < 250 • Corrected volemic status (negative raising legs mean arterial pressure [MAP]  variation < 10%)  • Written informed consent

Exclusion criteria:      MAP < 60mmHg   • Noradrenaline > 2 micrograms/Kg/min • Acute arrhythmias • Bleeding associated to hemodynamic instability • Need of re-surgery and/or mechanical circulatory assistance • Suspicion of neurological alteration • Chest tube with persistent air leak

Intervention: Intensive Alveolar Recruitment Group  Recruitment with opening pressures of 45 cmH2O in the airways, followed by  ventilation with PEEP = 13 cmH2O, during 4 hours of protective mechanical ventilation with VT = 6 mL/kg/ibw.

Control: Moderate Alveolar Recruitment Recruitment with opening pressures of 20 cmH2O in the airways, followed by ventilation with PEEP = 8 cmH2O, during 4 hours of protective mechanical ventilation with 574 VT = 6 mL/kg/ibw.  After a stabilizing period of four hours of controlled mechanical ventilation, the  patients will follow the routine weaning protocol and physiotherapy protocol of the institution

 

Outcome:

Primary outcome: Severity of pulmonary complications in the post-operative period [Time Frame: Participants will be followed for the duration of hospital stay, an expected average stay of 12 days after surgery]. Score of pulmonary complications adapted from previous publications 1,2 , with 5 degrees, where the higher one means death before hospital discharge, and degree (4) means the need of mechanical ventilation for more than 48 hours after surgery or after reintubation. The comparison will use this ordinal variable, representing the highest score achieved during the post-operative period

Secondary outcomes: Length of ICU stay----Length of hospital stay [Time Frame: From the day of surgery up to Hospital 598 discharge, an expected average of 12 days, and maximum censoring at day 28 after surgery] -- Incidence of barotrauma [Time Frame: Five days after surgery] Confirmed by X-ray. Test with logistic regression. Hospital mortality [Time Frame: From the day of surgery up to Hospital discharge or death, an expected average of 12 days, with no maximum censoring] Deaths occurred during hospital stay, tested with logistic regression

Authors’ Conclusions :  Among patients with hypoxemia after cardiac surgery, the use of an intensive alveolar recruitment strategy compared with a moderate recruitment strategy resulted in less severe pulmonary complications during the hospital stay.

Strengths: Homogenous group of patients with relatively healthy lungs.
Credible attempt to control variance
Extremely well matched samples
After extubation clinical staff were blinded to the patient
Intention to treat was maintained

Weaknesses: Single Centre..
Homogenous group of patients with relatively healthy lungs difficult to apply to general population
Very specific group of patients on periop bypass
Fluid balance was not included or controlled
Sedation was not protocolized

 

The Bottom Line: Pretty narrow patient set with a specific insult. However, the application of an aggressive recruitment manoeuvre with exposure to high levels of PEEP combined with LPV was a safe and potentially beneficial approach in the management of this patient group.

 

Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients*Mary Ann Barnes-Daly, MS, RN, CCRN, DC1; Gary Phillips, MAS2; E. Wesley Ely, MD, MPH, FCCM3,4 Critical Care Medicine

 

ABCDEF Bundle

1. Assess and manage pain
2. Both spontaneous awakening trials and spontaneous breathing trials.
3. Choice of sedation and analgesia
4. Delirium monitoring and management
5. Early mobility and exercise
6. Family engagement and empowerment

 

Developed to help implement PAD guidelines.

A prospective cohort quality improvement initiative- seven community hospitals.

Aim of the study was to examine relationship between ABCDEF bundle compliance and outcomes including hospital survival and delirium free and coma free days.

ABCDEF bundles were implemented for every patient for every day.

Use the guidelines of ICULiberation.org with some depth provided in the paper.

All elements had to be fulfilled for the bundle to have been complete.

 

Exclusions:

• Active ethanol/drug withdrawal
• Open abdomen
• Significant haemodynamic/respiratory instability
• New coronary ischaemia
• Therapeutic NMB
• Intubation within previous 6 hours without stabilisation

6064 patients included in the study, one quarter of which were on mechanical ventilation at some point.

Patients not receiving MV on a particular day and those who never received MV would not be eligible for the A,B or C elements of the bundles on those days.

Results

2 models used

1. Relative difference in the bundle effect on overall patient group
2. Relative difference in bundle effect on patients who were or were not transitioned to palliative care.

 

For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival.

For every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival.

When patients who received palliative care were removed from the calculations then those figures were 12% and 23% respectively.

 

ABCDEF vs DFCFDs

Total bundle compliance- for every 10% increase in compliance there was a 2% increase in DFCFDs.

 

Discussion

Compliance with the bundle was independently associated with better patient survival, more days alive and free of delirium and coma.

These findings help up even when the bundle was not implemented completely.

This study was complementary to previous studies in particular Belas etal, which was a CDC and prevention led quality improvement initiative  where in 51 hospitals all demonstrated improvement implementing some of the elements of the bundle.

There are some criticisms that implementing the bundle is difficult as it has so many parts making lasting change difficult.

The training involved, before actual implementation of the bundle, was felt to be very beneficial in and of itself.

The use of dedicated team members felt to be very important.

 

Limitations

Lacked strict protocols used in RCTs

Data collectors were invested in the performance of their units and colleagues/

However

“the strength of the experience lies in the fact that it was not an RCT. This real world experience can and should lend confidence to may hospitals that want to implement the PAD guidelines.”

 

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This is a chat about the ICU patient with problems with their swallow or dysphagia,  I had with Martin Brodsky (@MBBrodskyPhD), who is an Assistant Professor of Physical Medicine and Rehabilitation at the Johns Hopkins University School of Medicine.  He is a clinician, researcher and educator with interests in swallowing and swallowing disorders, head and neck cancer, neurologic communication disorders, and ethics. Jackie McRae (@Daisy_project) also joined us and she is a speech and language therapist and an NIHR research fellow undertaking a PhD to investigate intensive care practice in identifying and managing swallowing problems in cervical spinal cord injury (The Daisy Project).

In this conversation, we discussed martins latest research paper "Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors" Annals of the American Thoracic Society 2017 as well as exploring the causes of the swallow problems and some of the ways we can help prevent them.

Lots of food for thought and perhaps raises many questions for us to ponder.

This is an episode featuring Dr Paul Wischmeyer (@Paul_wischmeyer) who is a doctor at the Department of Anesthesiology and Duke Clinical Research Institute, Duke University Medical Center. I noticed he had tweeted about a presentation (Surviving the ICU-The Patient Experience: What Patients Need Their Doctors to Know) he gave which was available on YouTube and having watched it felt that others would appreciate hearing it too.I asked him if he would mind me producing it as a podcast to which he happily consented. I hope you find it valuable too.

Interview Questions for Advanced Critical Care Practitioners

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This is a very interesting chat I had with Dr Bronwen Connolly who is a Consultant Clinical research Physiotherapist and an NIHR post-doctoral research fellow about early mobilisation in the critical care.

She was asked to present at the ICS SOA 2016 to summarise key evidence published in 2016 examining physical rehabilitation in critical illness and also consider methodological trial design features in interpretation of results.

It would seem from the discussion that one of the main problems with the research is that there is no agreement on the end points which should be measured.

Some of the papers discussed were:

A Randomised Trial of an Intensive Physical Therapy Program for Patients with Acute Respiratory Failure

Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial

Standardised Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomised Clinical Trial.

Interview Questions for Advanced Critical Care Practitioners

In this podcast episode, Gavin Denton and I look at three recent papers, breaking them down to try to help us and you understand some of their conclusions and how they reached them.

Our notes can be found below.

Dynamic light application therapy to reduce the incidence and duration of delirium in intensive care patients: a randomised controlled trial.

Simons et al The Lancet 2016

Clinical Question

Continuous bright light therapy, delivered through a ceiling-mounted lighting system, in addition to regular lighting and daylight, would reduce the incidence and duration of ICU-acquired delirium.

Design

Single-centre, randomised, controlled trial.

Setting

ICU of the Jeroen Bosch Hospital in ’s-Hertogenbosch, Netherlands.

Population

Inclusion criteria: All consecutive ICU patients admitted to the ICU between July 1, 2011, and Sept 9, 2013, were screened for eligibility. Patients had to be 18 years or older with an expected ICU stay of at least 24 h.

Exclusion criteria: Those whose anticipated life expectancy was less than 48 h or who could not be assessed for delirium (eg, severe hearing or visual impairment, unable to understand Dutch, or severe mental impairment).

Intervention

A bright lighting system was installed into the ceiling of every ICU room. 800–1000 lux bluish-white light at the level of the patients’ heads, in line with previous reports that had showed effects with lighting therapy.

Mean illuminance was calculated for each patient per hour for the duration of his or her stay in the ICU. The lighting system was controlled from a central module, located in the nursing station, which was only accessible by the investigators.

For patients in the DLA group, lighting level and colour temperature rose from 0700 h onwards to peaks at 0900 h.

This light intensity was maintained until 1130 h.

To allow patients a period of rest, in accordance with normal daily practice in the ICU, the lighting level was decreased until 1330 h.

From 1330 h onwards, the level was again increased and was maintained until 1600 h, after which a gradual fall occurred over 1 h.

At 2230 h the light was switched off automatically.

Control

Patients in the control group were exposed to the standard lighting settings of 300 lux and 3000 K. The light could be turned on and off in the room and could be changed to a bright setting of 1000 lux for procedures.

Cumulative incidence of delirium was defined as the presence of delirium (at least one positive CAM-ICU screening) on at least 1 day during ICU stay.

The number of delirium-free and coma-free days in 28 days was calculated by subtracting the number of days patients had delirium or were comatose from 28.

Patients were deemed to be comatose when the CAM-ICU could not be scored and the Richmond Agitation Sedation Scale score was lower than –3 for the whole day.

All days without both conditions were defined as delirium-free and coma free days.

When a patient had been free from delirium for 48 h since a positive CAM-ICU score, the delirium was judged to have resolved and the 2 days were recorded as delirium free.

To detect differences in the effects of DLA and standard lighting settings on circadian rhythm, concentrations were measured of the melatonin metabolite 6-sulfatoxymelatonin and the stress hormone cortisol in urine. 6-sulfatoxymelatonin is a reliable proxy for melatonin secretion, and in healthy individuals, concentrations rise in the evening and peak during the night.

Cortisol concentrations are normally low during the night but rise in the early morning and peak at the time of awakening.

Outcome

Primary outcome: The primary outcome measure was the cumulative incidence of ICU-acquired delirium.

Secondary outcomes: Secondary outcome measures were:

• duration of ICU-acquired delirium (measured as the number of delirium-free and coma-free days in 28 days),
• duration of mechanical ventilation,
• length of stay in the ICU and in hospital overall, and
• mortality in the ICU and during the overall hospital stay.

Results

Delirium occurred in 137 (38%) of 361 patients in the DLA group and 123 (33%) of 373 in the control group (odds ratio 1⋅24, 95% CI 0⋅92–1⋅68, p=0·16 ).

The median numbers of delirium-free and coma-free days in 28 days were similar in the two groups. No association between the cumulative illuminance and the cumulative incidence of delirium.

When patients with early delirium were excluded, the median time to development of delirium was 4·4 days (IQR 2–6) in the DLA group and 4·0 days (2–7) in the control group (p=0·84). Among all patients with delirium, the median number of delirium-free and coma free days in 28 days was 20 (IQR 8–24) in the DLA group and 17 (7–25) in the control group (p=0·96).

Patients with delirium were:

• significantly older,
• more severely ill, and
• more had history of cognitive disturbances, alcohol abuse, and smoking than patients without

Patients with delirium had significantly longer stays in the ICU and hospital than those without, but mortality did not differ.

The percentage of patients who received mechanical ventilation, the duration of mechanical ventilation, use and types of sedatives, and use and cumulative amount of administered haloperidol did not differ significantly between the DLA and control groups.

Absence of sedation had no effect on delirium incidence (DLA group 17 [16%] of 105 vs control group 11 [10%] of 110, odds ratio 1⋅74, 95% CI 0⋅77–3⋅91, p=0·13) or the median number of delirium-free and coma-free days in 28 days (p=0·98).

Authors’ Conclusions

DLA delivered greater light exposure during patients’ ICU stays than did normal lighting, but the additional exposure did not reduce the cumulative incidence of ICU-acquired delirium. Furthermore, no differences were found for any of the secondary endpoints.

Some reasons why this study finds differently to those studies done in other environments.

First, in contrast to non-critically ill patients, most patients in the study were sedated and had their eyes closed during the acute disease phase. Since light exerts its effect on the biological clock by modulation of retinal input through photosensitive ganglion cells, closed eyes could have prevented some biological effects.

Second, sedatives can disturb the normal circadian rhythm, which might have counterbalanced the effects of lighting therapy. Again, therefore, effects of lighting therapy might only have been expected after the acute disease phase was over and the patient was awake. For patients who received no sedatives during their ICU stay there were also no differences in outcomes between study groups.

Is there a direct relationship between improved sleep and prevention of delirium? This is not known to be clear. It could be that disturbed circadian rhythms and delirium might be caused by brain inflammation which can occur in sepsis, trauma or MI for example. So ICU patients might be less susceptible than non-ICU patients to external cues such as daylight exposure.

Concentrations of melatonin or its urinary metabolite 6-sulfatoxymelatonin vary widely within and between ICU patients, and are affected to notable degrees by mechanical ventilation, adrenergic drugs, and sepsis.

Strengths

High adherence rate

Adequately powered

Regular measurements and fixed lighting schedule.

Weaknesses

Single centre study.

Blinding not possible

Did not/could not measure sleep- difficult to measure.

CAM-ICU single determination sensitivity is low.

 

 

Video laryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation.

Lewis et al. Cochrane Database of Systematic Reviews, 2016.

 

 Clinical question.

In patients requiring oral tracheal intubation, does the use of video laryngoscopy compared to traditional direct laryngoscopy techniques, reduce complications and failed intubation rates?

Design.

• Systematic review of adult oral intubation literature.
• Search of Medline, Embase, gov databases.
• PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) use for reporting the search process.
• Two reviewers searched titles and abstracts, and a third person was used as arbiter where there was disagreement on exclusion/inclusion.
• Cochrane risk of bias tool applied to each selected paper. Assessment of heterogeneity and publication bias also made.
• Only randomised controlled trials with human subjects and no mannequins selected.
• Study period between 1970 and February 2015.
• Primary outcome included failed intubation, and episodes of hypoxia.
• 8 secondary endpoints were included.
• 64 studies included in the final analysis including 7044 patients. 3 of 64 studies were pre-hospital. 17 studies were of a cross over design, comparing views with different scopes followed by a randomised intubation with a given scope. Airtrach studies that did not apply a camera to device were excluded.

 

Setting

• Intubation in elective and emergency surgery, emergency department and critical care patients.

 

Population.

• Adults over 16 years.

 

 Intervention/control.

• Video laryngoscopes (VL) of either classic or hyper-angulated type versus traditional direct laryngoscopy (DL).

 

 Outcome.

Primay outcomes.

• Failed intubation. 8 studies combined, VL vs DL statistically significant difference in favour of VL. OR 0.35, CI 0.19 to 0.65; 4127 participants. Moderate quality evidence.

 

• 3 studies, VL vs DL no statistically significant difference. OR 0.39, 95% CI 0.10 to 1.44; 1319 participants. Low quality evidence.

Secondary outcomes.

• First pass success. 35 studies, VL vs DL no statistically significant differences between groups OR 27, CI 0.77 to 2.09 4731 participants. Moderate quality of evidence.

 

• 2 studies. VL vs DL, statistically significant difference in favour of DL. OR 1.09, CI 0.65 to 1.82; 663 participants. Very low quality of evidence.

 

• Airway trauma. 22 studies, VL vs DL, statistically significant difference in favour of VL. OR 0.68, CI 0.48 to 0.96; 3110 participants.

 

• Time to intubation. Unable to combine due to heterogeneity.

 

• Type of VL. The C-MAC (most similar geometry to a Macintosh blade) had the lowest intubation failure rate of all VL devices.

 

• Unable to combine data.

 

• Failed intubation in predicted difficult airway. 9 studies. VL vs DL, statistically significant difference in favour of VL. OR, 0.28, CI 0.15 to 0.55; 830 participants. This held true for simulated difficult airway, OR, 0.18, CI 0.04 to 0.77; 810 participants.

 

 Author’s conclusion.

In patients with a predicted or difficult airway, VL may decrease the rate of failed intubation compared to DL.

 

Strengths.

• Significant effort to identify the relevant literature.
• Only included human studies.
• Clearly points out bias and heterogeneity of evidence.

 

Weaknesses.

• Very heterogeneous studies.
• Does not allow for clear delineation of hyper-angulated vs traditional geometry VL devices which may have significant performance differences.

 

Bottom line.

Base on data available up to February 2015, VL decreases failed intubation where the airway is predicted or found to be difficult.

 

 

Efficacy of High-Flow Nasal Cannula Therapy in Intensive Care Units: A Meta-Analysis of Physiological and Clinical Outcomes

 

Authors

Liesching et al

Clinical Question

A meta-analysis to compare the physiological and clinical outcomes of high-flow nasal cannula (HFNC) with standard oxygen (O2) or conventional noninvasive ventilation (NIV) in intensive care units (ICUs).

Design

Meta analysis

Search terms

1.    “oxygen inhalation therapy”
2.    “oxygen/administration and dosage”
3.    search #1 OR #2
4.    “high flow”  OR “high-flow”
5.    search #3 AND #4
6.     “high flow nasal cannula” OR “high flow nasal cannulae”
7.     HFNC  OR HHFN OR HHFNC
8.    search #5 OR #6 OR #7
9.    filter #8:  Humans

Excluded reviews/paediatrics/non ICU/non comparative/retrospective studies.

Identified 18 prospective studies.

Eleven articles are trials and seven are prospective comparative studies.

Results

In summary, the diagnoses include:

1253 (63.8%) cardiac or cardiothoracic surgeries,

359 (18%) pneumonia,

30 (1.5%) ARDS,

18 (0.9%) sepsis, 17 (0.8%) cardiogenic pulmonary edema, and 327 (16%) others.

 

Significant differences

Respiratory rate

The pooled t test shows a trend of lower RR in the HFNC group than the standard O2 group (21.6 vs 24.7,P=.059). Excluding CCU patients resulted in a more significant improvement (22.0 vs 25.6,P=.039).

Heart rate

The pooled t test shows a significantly lower HR in the HFNC group than the standard O2 group (89.1 vs 98.4,P=.033). Excluding CCU patients resulted in a more significant improvement (88.4 vs100.0,P=.013).

Arterial  Blood  Gas PaO2

The pooled t test shows a significantly higher PaO2 in the HFNC group than the standard O2 group (104.5 vs 90.0 mm Hg,P=.044). Excluding CCU patients resulted in a more significant improvement (109.4 vs 91.4 mm Hg,P=.015)

Dyspnea  Score

The pooled t test shows a significantly lower dyspnea score in the HFNC and standard O2 groups(2.7 vs 4.3,P=.046). Excluding CCU patients also resulted in a significantly lower dyspnea score (2.8 vs 4.6,P=.045).

Discomfort score

The sample size–adjusted pooled t test shows no significant difference in discomfort score when using HFNC versus standard O2 (1.19 vs 1.44, P 1⁄4 .435). Excluding CCU patients resulted in a significantly lower discomfort score in the HFNC group (0.98 vs1.96, P 1⁄4 .028).

Intubation  or  Reintubation  Rate

The OR calculated from total sample size shows no different intubation rate in the HFNC and standard O2 groups(OR=0.79, 95%CI: 0.39-1.21,P=.269). Excluding CCU patients resulted in a significantly lower intubation rate (OR=0.59, 95%CI: 0.37-0.97,P=.036).

In the table at the bottom of Figure 11, no difference in intubation rates was observed when comparing HFNC with NIV (OR=0.83, 95%CI: 0.62-1.11,P=.216). However, excluding CCU resulted in a significantly lower intubation rate (OR=0.58, 95%CI: 0.35-0.95,P=.032).

No significant differences

Arterial  Blood  Gas:  Oxygen  Saturation

Arterial  Blood  Gas:  PaO2/FIO2

Arterial  Blood  Gas:  PaCO2

Arterial  Blood  Gas:  pH

Dryness

Pulmonary function

Intensive care unit mortality

ICU length of stay

Hospital length of stay

 

Authors’ Comments and Conclusions

A high degree of heterogeneity across all the studies.

64% of the sample size is contributed by post cardiac or cardiothoracic surgery.

When excluding CCU patients, a majority of patients were diagnosed with pneumonia. For this subgroup of patients, the RR, HR, PaO2, dyspnea, and discomfort score were significantly improved with HFNC comparing to standard O2.

For patients with pneumonia, the HFNC group also showed better clinical outcomes including a significantly lower intubation rate, a trend of lower ICU mortality, and a shorter ICU length of stay, comparing to standard O2. Comparing with NIV, only when excluding CCU patients, the limited data showed better clinical outcomes including lower intubation rate and ICU mortality in the HFNC group.

 

Interview Questions for Advanced Critical Care Practitioners

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Selecting the intervention in Intubated patients: Evidence, Guidelines and Clinical Application

This is a chat with Rachael Moses (@rachaelmoses) who is a consultant respiratory physiotherapist. I noticed from a twitter post that she had been at a meeting and presented on the above topic. She was kind enough to chat with me for the podcast. We talked about a number of issues but mainly discussed the various ways in which we can help the ventilated patient to clear their secretions.

I certainly found out a few things I didn't know about and some equipment I had not heard of before. We discussed the Biphasic Cuirass Ventilation, the inCourage® Airway Clearance Therapy, The Vest® System, Electromed SmartVest® System, Intrapulmonary Percussive Ventilation IPV, the MetaNeb® Hill Rom and Mechanical In-Exsufflation.

Lots of new and old techniques as well as the more traditional hands-on ways of getting the secretions up and out.

Some of the research papers we discussed are below.

Preliminary evaluation of high-frequency chest compression for secretion clearance in mechanically ventilated patients.

Evaluation of the safety of high-frequency chest wall oscillation (HFCWO) therapy in blunt thoracic trauma patients Anderson et al

Efficacy of mechanical insufflation-exsufflation in extubating unweanable subjects with restrictive pulmonary disorders.

 

Interview Questions for Advanced Critical Care Practitioners

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

You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.

Thank you.

In this podcast episode, Gavin Denton and I look at three recent papers, breaking them down to try to help us and you understand some of their conclusions and how they reached them.

Our notes can be found below.

Video laryngoscopy vs direct laryngoscopy on successful first pass orotracheal intubation amongst ICU patients. JAMA Jan 2017

Authors

Lascarrou et al

Clinical Question

Routine use of video laryngoscopy for orotracheal intubation of patients in ICU increases the frequency of successful first pass intubation compared with the use of the Macintosh direct laryngoscope.

Design

Non blinded, multi centre, open label, 2 parallel group RCT

Setting

7 ICUs in France

Population

Inclusion criteria: ICU admission and need for intubation to allow mechanical ventilation.

Exclusion criteria: 1. Contraindications to intubation e.g. unstable spinal lesion. 2. Insufficient time to include and randomise. 3. < 18 yrs.  4. Pregnant or breastfeeding…..and others…..

Intervention

Using McGrath MAC video laryngoscope- this device was chosen because intubation technique is similar to Macintosh, a previous study suggests benefits for ICU intubation, the small size of the device enabled bedside use and cost was relatively low.

•         Pre ox with BVM at 15l min for at least 3 minutes, or vent in non-invasive mode providing 100% oxygen or HFNC at 60l/min with 100% for 3 minutes.
•         Etomidate or ketamine/sux or roc.
•         Tube position confirmed with capnography over 4 or more breaths.
•         Sellick at discretion of clinician.
•         If first pass failure then following technique chosen according to French guidelines.

Control

Same as above but using Macintosh laryngoscope.

Outcome

Primary outcome: Proportion of patients with successful first pass orotracheal intubations which was defined based on a normal appearing waveform of the partial pressure of end tidal exhaled carbon dioxide curve over 4 or more breathing cycles.

Secondary outcomes:

• proportion of patients with successful orotracheal intubation at any attempt.
• total time to successful orotracheal intubation
• grade of glottis visibility.
• percentage of glottic opening score
• proportion of patients with difficult intubations
• proportion of patients intubated using alternative techniques
• Complications (incl death, cardiac arrest, cardiovascular collapse, hypoxemia  and others)
• duration of mechanical ventilation
• ICU length of stay
• ICU mortality
• 28 day mortality

Sample size

Needed 185 patients in each arm assuming a first pass success rate with Dl of 65% and DL increasing this to 80%.

Results

Primary Outcomes

366 patients were successfully intubated.

There was no significant difference with first pass intubation- VL (126 0f 186 patients, [67.7%]); DL (130 of 185 patients, [70.3%]).

Frequency of first pass failure was not significantly different with VL (odds ratio 1.12) both after adjustment for operator expertise (randomization stratification factor) and after adjustment for the MACOCHA score (OR, 1.10 [95% CI, 0.69-1.75]; P = .69).

Secondary Outcomes

VL group had better glottis visualisation, glottis opening score and the bougie was used more often.

Most first intubation attempts were by non experts.

Not surprisingly first intubation attempts were successful more often when performed by experts.

Median duration of intubation of 3 minutes did not differ between groups.

Proportion of patients with severe life threatening complications was higher in the video laryngoscopy group (9.5% vs 2.8% in the direct laryngoscopy group; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not significantly so.

Duration of mechanical ventilation, ICU length of stay, sepsis-related organ failure assessment score on day 1, sepsis related organ failure assessment score on day 2, ICU mortality, and 28-day mortality did not differ between the 2 groups.

Authors’ Comments and Conclusions

“Improved glottis visualization with video laryngoscopy did not translate into a higher success rate for first-pass intubation because tracheal catheterization under indirect vision was more difficult, in keeping with earlier data.”

“The better visualization of the glottis with video laryngoscopy might lead to a false impression of safety when orotracheal intubation is performed by non experts. The subgroup analyses did not identify factors associated with life-threatening complications with video laryngoscopy. In addition, poorer alignment of the pharyngeal axis, laryngeal axis, and mouth opening despite good glottis visualization by video laryngoscopy can lead to mechanical upper airway obstruction and faster progression to hypoxemia”

“Use of a gum elastic bougie during the first intubation attempt was more common with video laryngoscopy. Due to the indirect visualization of the glottis with video laryngoscopy, some manufacturers recommend using an intubation stylet.”

Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications.

Strengths

Multi centre RCT

Objective primary outcome measure (capnography).

Weaknesses

Assessed only single type of laryngoscope.

Other blades might have had different outcomes.

Most of first attempts were made by non experts.

Blinding not feasible.

 

Protective mechanical ventilation in United Kingdom critical care units: A multi-centre audit.

Newell. C et al 2016. 

Clinical question.

How compliant are intensive care units in the south-west of England to lung protective ventilation and low/high PEEP titration based on ARDSnet protocols.?

Design.

• Observational study.
• Prospectively collected data taken in 2 hourly increments over a 24 hour period.

Setting.

• 7 intensive care units in the Severn region, 9 intensive care units in Wessex region.

Population.

• Adult intensive care units.
• Mainly general intensive care units.
• All patients ventilated with a mandatory mode of ventilation.
• The Wessex area excluded patients who required tight regulation of pCO2.

Primary data endpoints.

• All patients had predicted body weight calculated based on height measurement. The desired total volume was considered to be less than 6.5ml/Kg based on the low vs high tidal volume ARDSnet study.
• Compliance to ARDSnet PEEP protocol was based on the low tidal volume table. This titrated PEEP against FIO2 requirements.

Outcome.

• Data from 80 patients included in the study.
• One intensive care unit did not supply data due to the pCO2 exclusion (neuro ITU).
• The mean tidal volume across both regions was 7.2ml/Kg.
• Overall compliance to 6.5ml/kg ventilation was 34%.
• Patients ventilated on a volume control mode were had a statistically significantly lower tidal volume than patients on pressure control modes of ventilation p-value 0.0001.
• There was a significant difference in mean tidal volumes between the two regions which related to a high use of volume control ventilation in one region compared to the other.
• 72% of patients were compliant to the ARDSnet low PEEP table based on FIO2 requirements.

Author’s conclusion.

There is a large variation in the delivery of lung protective ventilation in the UK which may have adverse consequences. Volume control ventilation seems to convey better compliance to lung protective ventilation.

Strengths.

• A good cross section of intensive care units which may make this generalisable to UK intensive care ventilation practices.

Weaknesses.

• It is not clear why plateau airway pressure was not measured in this study as this is a key feature of the original ARDSnet protocol.
• Staff on the intensive care units were aware of the study and this may have induced a Hawthorn effect.

Bottom line.

Compliance to 6ml/Kg lung protective ventilation to all ventilated patients is poor.

Links.

Protective mechanical ventilation in United Kingdom critical care units: A multicentre audit. Newell. C et al 2016. DOI: 10.1177/1751143716683712
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342: 1301–1308. 
ARDSnet PEEP protocol http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

 

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival JAMA 2017

Authors

Anderson et al

Clinical Question

The aim of the current study was to evaluate the association between tracheal intubation during adult in-hospital cardiac arrest and survival to hospital discharge using the multicenter Get WithTheGuidelines–Resuscitation (GWTG-R) registry (a prospective quality improvement registry of inhospital cardiac arrest in US hospitals).

This study also aimed to assess whether this association was modified by the first documented rhythm (shockable vs nonshockable) or other patient and event factors explored in prespecified subgroups.

Design

Multicenter, retrospective, observational, matched cohort study which analyzed data from the GWTG-R registry, a prospective quality improvement registry of inhospital cardiac arrest in US hospitals.

Setting

American hospitals.

Population

Inclusion criteria: This study included adult patients (aged ≥18 years)with an index cardiac arrest for which they received chest compressions.

Exclusion criteria: Patients who had an invasive airway in place at the time of the cardiac arrest (including tracheal tube, tracheostomy, laryngeal mask airway, or other invasive airways but not including nasopharyngeal or oropharyngeal airways).

Hospital visitors and employees .

For the main analysis, patients with missing data on tracheal intubation, covariates (except race, for which a “not reported” category was created), and survival. This included patients with missing or inconsistent data on timing of tracheal intubation, timing of epinephrine administration, or timing of defibrillation (in those with a shockable rhythm). These patients were included after imputation of missing values in a preplanned sensitivity analysis (see “Statistical Analysis”).

Intervention Tracheal intubation was defined as insertion of a tracheal or tracheostomy tube during the cardiac arrest.

The end of the cardiac arrest was when the patient had return of spontaneous circulation (ROSC) or when resuscitation was terminated without ROSC.

The time to tracheal intubation was defined as the interval in whole minutes from loss of pulses until the tracheal tube was inserted.

Control

Outcome

Primary outcome: The primary outcome was survival to hospital discharge.

Secondary outcomes:  Secondary outcomes were ROSC and favorable functional outcome at hospital discharge. ROSC was defined as no further need for chest compressions (including cardiopulmonary bypass) sustained for at least 20 minutes.

A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome consistent with current Utstein guidelines.

Results

The study population included 108 079 patients from 668 hospitals.

The median age was 69 years, and 45 073 patients (42%) were female.

Among the population, 75 579 patients (69.9%)were intubated, with 71 615 (66.3% of all patients and 94.8% of those intubated) intubated within the first 15minutes.

The median time to tracheal intubation in those intubated within the first 15 minutes was 5minutes (IQR, 3-8 minutes).

Among 88 749 patients with an initial non shockable rhythm, 61 264 (69.0%) were intubated within 15 minutes, with a median time to intubation of 5 minutes (IQR, 3-8minutes).

Among 19 330 patients with an initial shockable rhythm, 10 351 (53.5%) were intubated within 15 minutes. The median time to intubation in these patients was 5 minutes (IQR, 3-8 minutes).

Primary outcome:

A total of 24 256 patients (22.4%) survived to hospital discharge.

In the unadjusted analysis, patients intubated within the first 15 minutes had lower survival compared with those not intubated: 12 140 of 71 615 (17.0%) vs 12 116 of 36 464 (33.2%), respectively (RR = 0.58; 95% CI, 0.57-0.59; P < .001).

Among the study population, 67 540 patients (62.5%) had ROSC (data were missing for 7 patients). The proportion of patients with ROSC was lower in those intubated within the first 15 minutes compared with those not intubated: 42 366 of 71 611 (59.2%) vs 25 174 of 36 461 (69.0%), respectively (RR = 0.75; 95% CI, 0.73-0.76;P < .001).

Of the 103 448 patients without missing data on functional outcome, 16 504 (16.0%) had a good functional outcome.

Time-Dependent Propensity Score–Matched Analysis

43 314 intubated patients [exposed group] matched 1:1 to 43 314 patients without intubation during the same minute [unexposed group], although these patients could have been intubated later.

For patients in the exposed group, the median time to tracheal intubation was 4minutes.

Among the unexposed group, 29 539 patients (68.2%) were intubated at some timepoint after the matching.For these patients, the time to intubation was 8 minutes (IQR, 5-12 minutes).

In this matched cohort, survival was lower among the exposed group than among the unexposed group: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (RR = 0.84; 95% CI, 0.81-0.87; P < .001).

The proportion of patients with ROSC was lower among the exposed group than among the unexposed group: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97;95%CI,0.96-0.99;P < .001).

Good functional outcome was also lower among the exposed group than among the unexposed group: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001).

Sub Group analysis

There was a significant interaction for initial rhythm (P < .001) such that tracheal intubation was more strongly associated with a lower likelihood of survival in those with an initial shockable rhythm (RR = 0.68; 95% CI, 0.65-0.72) compared with those with an initial non shockable rhythm (RR = 0.91;95%CI,0.88-0.94).

In those without preexisting respiratory insufficiency, intubation was associated with lower likelihood of survival (RR = 0.78; 95% CI, 0.75-0.81), whereas no association was seen in those with preexisting respiratory insufficiency (RR = 0.97;95%CI,0.92-1.02).

Authors’ Conclusions

In this large,multicenter, retrospective, observational,matched cohort study, tracheal intubation at any minute within the first 15 minutes during in-hospital cardiac arrest, compared with no intubation during that minute, was associated with a 3% absolute reduction and 16% relative reduction in survival to hospital discharge.

Intubation was also associated with a 2% absolute reduction and 3% relative reduction in ROSC and a 3% absolute reduction and 22% relative reduction in good functional outcome at hospital discharge.

An observational study (n = 470) from 1990 of patients with in hospital cardiac arrest found that tracheal intubation during the cardiac arrest was associated with increased mortality  similar to an observational study from 2001 (n = 445).

A meta-analysis from 2013 of observational out-of-hospital cardiac arrest studies found that tracheal intubation compared with basic airway management was not associated with ROSC but was associated with decreased survival.

Multiple mechanisms could explain a potential causal relationship between tracheal intubation and poor outcomes:

• Tracheal intubation might lead to a prolonged interruption in chest compressions.
• Tracheal intubation might lead to hyperventilation and hyperoxia, which are associated with poor outcomes.
• Tracheal intubation could delay other interventions such as defibrillation or epinephrine administration.
• Delays in the time to success of intubation could result in inadequate ventilation or oxygenation by other means.
• Unrecognized esophageal intubation or dislodgement of the tube during the cardiac arrest could lead to fatal outcomes. Potential beneficial effects of intubation include better control of ventilation and oxygenation as well as protection from aspiration.24 Moreover, once an advanced airway is established, chest compressions may be provided in a more continuous fashion.

Tracheal intubation was associated much more strongly with decreased survival among patients with an initial shockable rhythm (32% relative decrease) compared with those with an initial non shockable rhythm (9% relative decrease). These findings may indicate that the potential detrimental effects of intubation are more pronounced in patients with a shockable rhythm, for whom other interventions such as early defibrillation are more relevant.

Strengths

Weaknesses

US only based.

Unable to identify some of the potential confounders.

Data on unsuccessful intubation attempts not available- potential bias.

Data missing on a least one variable for 25% of the patients.

The Bottom Line

Interview Questions for Advanced Critical Care Practitioners

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I was fortunate to be able to have a good chat at the ICS State of the Art 2016 conference with Roger Harris (@RogerrdHarris), Danni Bear (@Danni_Dietician), Ella Segaran @ESegaran) and Todd Rice about their interpretation of the Nutrition Guidelines released last year. Todd is one of the original authors and both Ella and Danni are senior dieticians with an obvious interest in the interpretation of the guidelines.

I think we cover a number of important points during the discussion. If you have any comments then please don't hesitate to let me know.

Interview Questions for Advanced Critical Care Practitioners

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN)

This is an update and expansion of the previous  nutrition guidelines and this is a summary of the some of the key points. I discussed this particular document at the Intensive Care Society State of the Art 2016 with Danielle Bear (@Danni_dietician), Ella Segaran (@ESegaran), Roger Harris (@RogerRdHarris) and Dr Todd Rice and that will be available as a podcast very soon so that you can listen to the discussion. When it is I will make sure I include the link on this page.

Initiating Enteral Nutrition

Dosing of EN

Monitoring Tolerance and Adequacy of EN

Selection of Appropriate Enteral Formulation and Adjunctive Therapy

When to Use Parenteral Nutrition (PN).

Nutrition Support in Particular Conditions.

Pulmonary Failure

 Renal and Hepatic Failure

 Acute Pancreatitis

 Sepsis

 Chronically Critically Ill

 Obesity in Critical Illness

 

Nutrition Assessment

There is recommendation of the use of the Nutrition Risk Screening(NRS)/NUTRIC score for all patients who are expected not to be able to have sufficient volitional intake. Of all the other scores used these are the only ones that determine both nutrition status and disease severity.

NRS score >3 is a patient at 'risk' and those at 'high risk' with an NRS score equal to or greater than 5.

If interleukin 6 is measured this value would be greater than 6 in the NUTRIC score. However as there are rarely the facilities to measure this value then a value of 5 or greater indicates 'high risk in the NUTRIC score also.

It is anticipated that ultrasound will emerge as a useful tool in measuring muscle mass and determine changes in muscle tissue and even CT scans of the skeletal muscle could be done. Both of these will not be too common currently due to cost and lack of trained personnel, however it is an aspiration towards the future. The same could be said of indirect calorimetry measurements which are also recommended.

Where there is an absence of indirect calorimetry then energy requirements should be calculated using published predictive equations or simplistic weight based equations. Even where indirect calorimetry is available it is prone to error in the ICU due to presence of air leaks or chest tubes, supplemental oxygen, ventilator settings and renal replacement therapy.

However calculated energy expenditure should be reevaluated at least once per week.

There is also an emphasis on the provision of protein, being the most important macronutrient for healing wounds, supporting immune function and maintaining lean body mass.

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Initiating Enteral Nutrition

Enteral Nutrition (EN) should be initiated within 24-48 hours. The specific reasons for providing EN are to:

• maintain gut integrity
• modulate stress
• modulate the systemic immune response
• attenuate disease severity

Studies have shown a significant reduction in mortality with the introduction of early EN. There is also a recommendation to use EN rather than parenteral nutrition (PN). Studies have shown a reduction in infectious morbidity and ICU LOS when comparing EN to PN.

There is no need to wait for overt signs of bowel activity i.e. bowel sounds. These indicate only contractility and do not relate to mucosal integrity, barrier function or absorptive capacity.

On most critically ill patients it is acceptable to initiate NG feeding whilst those at risk of aspiration should have feeding initiated lower down the GI tract. If small bowel access is difficult then feeding should be initiated in the stomach rather than wait.

EN can be given to those stable patients on low dose vasopressors but should be withheld on patients who are hypotensive, have catecholamine agents or who are requiring escalating doses to maintain stability.

For patients on vasopressors any sign of gut intolerance:

• abdominal distension
• increasing NG output
• decreased passage of stool and flatus
• hypoactive bowel sounds
• increasing metabolic acidosis

then the EN should be with held.

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Dosing of EN

Patients at low risk with normal baseline nutrition and low disease severity (NRS less than or equal to 3 or NUTRIC less than or equal to 5) who cannot maintain volitional intake do not require specialised nutrition therapy. They should be offered oral intake and reassessed daily.

Trophic or full EN is appropriate for patients with ALI or ARDS and those expected to have a ventilation period greater than 72 hours.

In the high-risk patient, efforts should be made to provide greater than 80% of target within 48-72 hours. Studies have shown that greater than 50-60% of goal energy may be required to prevent increases in intestinal permeability and systemic infection in burn and bone marrow patients, promote faster cognitive return in head injury patients and to reduce mortality in high-risk hospitalised patients.

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Monitoring Tolerance and Adequacy of EN

For me, this is one of the main points to come out of this document.

So some facts first!

• 97% of nurses assess tolerance by gastric residual volumes (GRVs) alone.
• The most frequently cited thresholds for withholding feed were 200 and 250mls.
• Less than half of patients ever reach their target goal energy intake during their ICU stay
• Cessation of EN occurs in >85% of patients for an average of 8%-20% of the infusion time

Raising the cutoff value for GRVs from a lower number of 50-150ml to a higher number of 250-500ml DOES NOT increase the incidence of regurgitation, aspiration or pneumonia.

Use of GRVs leads to:

• enteral access clogging
• inappropriate cessation of EN
• consumption of nursing time
• may adversely affect outcomes through reduced volume of EN delivered.

So the recommendation is that GRVs should NOT be used and, if they are used, the cut off should be 500mls.

The patient should be monitored for other signs of intolerance (see above).

Another area which drew my attention especially was the recommendation that there should be a volume based feeding protocol which should be ICU or nurse-driven. These protocols would:

• define goal EN infusion rate
• designate more rapid start-ups
• provide specific orders for handling GRVs, frequency of flushes and conditions under which EN may be adjusted or stopped.

Such strategies have been shown to increase the overall percentage of energy provided.

These are the free to access references that are used....go have a read and see what you think...

Enhanced protein-energy provision via the enteral route in critically ill patients: a single centre feasibility trial of the PEP uP protocol

Outcomes in Critically Ill Patients Before and After the Implementation of an Evidence-Based Nutritional Management Protocol

Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults. A Cluster Randomised Controlled Trial

The aim of these protocols is to empower nurses to increase feeding rates to make up for volume lost while EN is held.

Aspiration is always of great concern in the Intensive Care patient and the guidelines acknowledge this.

Patients should be assessed for risk of aspiration which may be identified by a number of factors:

• inability to protect the airway
• presence of a Naso enteric enteral access device
• mechanical ventilation
• age > 70 years
• reduced level of consciousness
• poor oral care
• inadequate nurse:patient ratio
• supine positioning
• neurologic deficits
• gastroesophageal reflux
• transport out of ICU
• use of bolus intermittent EN

....phew! That covers a lot of my patients!

Where there is a risk of aspiration the patient should be feed beyond the pylorus, so NJ feeding, they should not be fed by bolus EN and there should be the use of prokinetics, and those prokinetics would include metoclopramide and erythromycin. Whilst not improving long-term ICU outcomes these drugs have been shown to improve gastric emptying.

Nursing measures, such as head elevation between 30-45 degrees and the use of chlorhexedine mouth washes,  are recommended. Other steps to decrease aspiration risk include reducing the level of sedation/analgesia when possible and minimising transport out of the ICU for diagnostic tests and procedures (although I think we only ever take patients for these tests when absolutely necessary).

Enteral feeding should not be discontinued due to the presence of diarrhoea until other causes have also been investigated. These could include:

• type and amount of fibre in formula.
• osmolality of formula
• delivery mode.
• medications:
  • antibiotics
  • PPIs
  • prokinetics
  • glucose-lowering agents
  • NSAIDs
  • SSRIs
  • Laxatives
• infectious etiologies including C Diff.

Assessment of diarrhoea should then include abdominal examination, quantification of stool, stool culture for C Diff, serum electrolytes and review of medications.

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Selection of Appropriate Enteral Formulation and Adjunctive Therapy

There is a recommendation to start with standard feed when initiating EN as there has been no clear benefit shown to using speciality formulas in areas such as the surgical ICU or medical ICU. They also do not recommend the use of immune modulation formulations.

They make no recommendations around the use of fish oils, borage oil and antioxidants in patients with ARDS and ALI due to conflicting data.

Consideration needs to be given to the use of a mixed fibre formulation in those patients with persistent diarrhoea. Such a formulation is not recommended for routine use in the patient to promote bowel regularity.

There is no recommendation as to the use of probiotics in the general ICU population. The use of probiotics would seem theoretically sound but there has not been a consistent benefit demonstrated. Antioxidants (vitamin E and C) and trace minerals might be useful especially in burns, trauma and critical illness requiring mechanical ventilation.

Finally, they recommend that glutamine is not added routinely- outcomes from the use of glutamine showed no significant benefit on mortality, infections or hospital LOS.

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When to Use Parenteral Nutrition (PN).

In the low nutrition risk patient, where early EN is not feasible, then PN should be witheld for the first seven days whereas in the patient at high nutrition risk in the same circumstances then PN should be started as early as possible.

In the patient where EN is not meeting greater than 60% of their needs then PN should be started after 7-10 days.

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Nutrition Support in Particular Conditions.

Pulmonary Failure

Speciality high fat/low carbohydrate formulations designed to manipulate the respiratory quotient and reduce carbon dioxide production are not recommended in ICU patients with acute respiratory failure.

Recommendation is made for the use of fluid restricted energy dense formulations in this group of patients and also that the serum phosphate levels should be monitored closely. Phosphate is crucial in the synthesis of ATP and 2,3-DPG which are both crucial for normal diaphragmatic contractility and optimal pulmonary function.

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Renal and Hepatic Failure

Patients in ARF or AKI should be put onto a standard formula. If significant electrolyte disturbances occur then formulations designed for renal failure should be considered. Those patients on CRRT should receive increased protein as significant amino acid loss is associated with CRRT.

A dry weight should be used instead of actual weight in the patient in hepatic failure when determining energy and protein requirements. This then accounts for the possibly significant ascites and oedema they may be suffering.

EN should be used in preference to PN in the patient with liver failure and a standard formulation should be used.

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Acute Pancreatitis

Disease state may change quickly in this condition so frequent reassessment is needed. For those patients with a mild acute pancreatitis specialised nutritional therapy is not recommended but an effort to work towards normal oral intake instead.

For those with moderate to severe pancreatitis an NG tube should be inserted and there should be efforts made to advance to goal within 24-48 hours after admission.

Standard formula should be used in the severe pancreatitis patient and EN is preferred to PN as it has been shown in several studies and meta-analysis to reduce mortality, LOS and surgical interventions.

Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis.

Meta-analysis of enteral nutrition versus total parenteral nutrition in patients with severe acute pancreatitis. 

In moderate to severe patients who have an intolerance to EN measures should be taken to reduce the intolerance such as:

• starting EN as early as possible to minimise the period of ileus.
• diverting level of EN more distally.
• change to a formula that contains small peptides or one that is nearly fat-free.
• switch from bolus to continuous.

Probiotics should be added for this type of patient.

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Sepsis

EN therapy should be introduced within 48 hours from diagnosis when resuscitation is complete and the patient is haemodynamically stable.

In the acute phase, where possible, EN should be used exclusively.

There is no recommendation regarding selenium, zinc and antioxidant supplementation.

A recommendation is made for trophic feeding for the initial phase of sepsis advancing to 80% within the first week and there should be delivery of 1.2-2g protein/kg/day.

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Chronically Critically Ill

Defined as those with persistent organ dysfunction requiring ICU LOS greater than 21 days.

They should be managed with aggressive high protein EN therapy. In a series of studies, patients demonstrated chronic inflammation and a maladaptive immune response that contributed to secondary nosocomial infections and severe protein catabolism.

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Obesity in Critical Illness

Early EN should start within 24-48 hrs. There is no difference between this type of patient and those that are not obese. 57% of hospitalised patients with a BMI of greater than 25 show signs of malnutrition! A couple of quotes are needed here I feel to reinforce a couple of key points:

The reasons for the surprisingly high rate of malnutrition in obese patients may stem in part from unintentional weight loss early after admission to the ICU and a lack of attention from clinicians who misinterpret the high BMI to represent additional nutrition reserves that protect the patient from insult.

The obesity paradox may contribute to clinicians’ illusion that obese patients do not need nutrition therapy early in their ICU stay. The mortality curve for BMI is U-shaped, with the mortality highest in class III severely obese patients with BMI >40 and in people with BMI <25. Mortality is lowest in subjects with BMI in the range of 30–40 (class I and II obesity). This protective effect of moderate obesity is the obesity paradox.

This section of the paper highlights a number of the problem the obese patient will have in the ICU such as:

• technical difficulties of management
  • vascular access
  • performing tracheostomy
  • interpreting radiologic images
• altered drug metabolism
• Predisposition to heart failure
• Respiratory abnormalities
• Liver pathology
  • nonalcoholic fatty liver
  • steatosis- accumulation of fat in the liver
  • cirrhosis
• Compared lean counterparts:
  • increased morbidity
  • greater incidence of infection
  • prolonged hospital and ICU LOS
  • increased risk of organ failure
  • Longer duration mechanical ventilation

As a consequence of all of these factors there is a recommendation for the nutrition assessment of the obese patient to focus on evidence of central adiposity, metabolic syndrome, sarcopenia (loss of skeletal muscle mass), SIRS and other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality.

There is a recommendation for high protein hypocaloric feeding to preserve lean body mass, mobilise adipose stores and minimise the metabolic complications of overfeeding.

Promotion of weight loss is achieved by aiming for 60-70% of target energy requirements. Some degree of weight loss may increase insulin sensitivity, facilitate nursing care and reduce risks of comorbidities.

Due to the intentional permissive underfeeding of the obese patient, there should be additional monitoring to assess for worsening of:

• Hyperlipidemia
• Hyperglycemia
• Hypercapnia
• Fluid overload
• Hepatic fat accumulation

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It is very important to restate that these are guidelines only. Each patient should be assessed individually and care should be taken to take account of the units they are being nursed in and the resources that are available, both financial and personnel.

These are very extensive guidelines and if you want to read more or see the many references then go to this site here.

If you have any views on any of the above then please feel free to get in touch or leave a comment on the site.

Critical Care Nutrition

ESPEN Guidelines for Nutrition Screening

Desarmenien. The chronic critical illness: a new disease in intensive care. Swiss Med Wkly 2016;146:w14336

This paper is one from the Swiss Medical Weekly 2016 and is a description of the efforts to develop what they call a multi modal care management approach to those patients at risk of chronic critical illness. They call these patients PLS from the french term 'Patient Long Sejour'.

In 2006 there was a realisation that this kind of patient needs to be managed differently from those in the acute phase and the formation of an interdisciplinary team helped in the development of a new approach.

They defined the chronically critically ill (CCI) as those with a length of stay in the ICU of greater than seven days with a second criterion being the necessity for support by sophisticated means available only in the ICU. This group of patients;

• accounts for 12-18% of the 2500 patients admitted each year.
• Stay as long as 13.8 days.
• consume up to 52% of ICU resources.
• had a mortality of 15% (compared with 8-12% of general ICU population).

Their problems are many but some of the ones worthy of note are;

• Neuromuscular weakness
• ICU paresis
• Swallowing problems
• Muscle loss and increased adipose tissue
• Anxiety
• Depression
• Difficulty with communication.

Caregivers need to be able to have great skill in human relationships. There may be much conflict for these patients amongst them and their family or their carers or even their family and their carers. These conflicts are associated with burnout of their carers.

An attempt to pool this kind of patient between 2006 and 2009 resulted in exhaustion of the team members. It failed for several reasons;

• burden of care
• difficult relationships with family members
• uncertain progress
• slow evolution of PLS.

One of the learning points from this attempt was that a specialist nurse should be used in the future to help be a resource for this type of patient and their family and to assist in training the carers in looking after this type of patient.

They did identify some specific actions to be taken to ensure that the PLS patient is identified and helped as early as possible;

• After seven days the patient is highlighted with a PLS sticker and algorithm of care on the patient monitor
• Early mobilisation is encouraged. Muscle tone is assessed regularly by the physios.
  • Muscle mass diminishes by 2-% per day during critical illness
  • A weekly consultation with a specialist in rehabilitation to help the physios select the appropriate therapies.
• Under or over feeding of critical patients is associated with an increase in complications, costs and mortality. A dietitian is needed to ensure that this is monitored properly.
• They may also have swallowing problems which create a threat of inhalational pneumonia, so small calibre feeding tubes and access to a speech therapist are important.
• Neurocognitive assessment using modified mini mental state examination is helpful to anticipate, detect and monitor potential neurocognitive disorders.
• Visual calendar to help decrease patient disorientation.
• Diaries- patients will often have delusional memories, nightmares and/or hallucinations. Diaries can help reconstruct the patients ITU experience and has been shown to prevent PTSD.
• Multidisciplinary conferences whose purpose is to redefine the short medium and long-term therapeutic goals.
• Patients can experience a real loss when they are moved out of the intensive care unit and preparation is thus essential. the team organises an interview with the next caregiver team

After implementing these changes re admissions have decreased between 2014-2015. They are presently training carers in the use of massage to decrease the anxiety and pain of the patients as well as their sleep quality and sleep is the subject of their next research project.

Marchioni. Chronic critical illness: the price of survival. Eur J Clin Invest 2015;epublished November 9th

This paper addresses some of the pathophysiological aspects related to the development of Chronic Critical Illness. It first acknowledges that an absolute definition of CCI is not available but speculates that prolonged mechanical ventilation might be one of the factors. Prolonged in this instance is quoted as being 21 days of ventilation for a minimum of 6 hours per day. This population is growing with some studies reporting up 5-10% of patients admitted to ICU requiring prolonged mechanical ventilation. Only 10% of CCI patients achieve functional autonomy and live in their own home at 1 year after the onset of the acute condition requiring admission to ICU.

Whilst respiratory failure is the main feature of CCI there are other features which are often present which include:

• Myopathy
• Neuropathy
• Loss of lean body mass
• Delirium
• Nutritional deficiency
• Immobility

There are no biomarkers that can assist in predicting the development of CCI but risk factors include old age, comorbidities, sepsis and ARDS.

CCI is associated with persistent systemic inflammation and those patients presenting with higher inflammation levels at disease onset show worse progress and higher incidence of multiple organ failure. Those older patients have a chronic increase of some of the inflammatory markers putting them more at risk as a consequence.

There is some impairment of the regulation of the processes aimed at limiting damage associated with inflammation which might be involved in the progression from the acute to the chronic phase and even a low inflammatory state may play a role.

Endocrine abnormalities play a large part in the development of the acutely critically ill patient but have not been recognised for the chronically critically ill patient. Some of these processes are complex and perhaps merit more study in depth but to summarise the patients cortisol levels are very important in their attempts to fight disease. Cortisol causes a positive haemodynamic effect through intravascular fluid retention and increase in inotropic and vasopressor response to catecholamines and angiotensin II. It also has an anti-inflammatory effect. During sepsis, due to relative adrenal insufficiency, cortisol production is insufficient to maintain haemodynamic stability.

Another endocrine impairment is hyperglyceamia secondary to the response to acute stress. Once hyperglyceamia is present, it may even persist.

Some of the problems are best summed up by this quote from the paper:

The chronic process of a critical illness involves significant changes in neuroendocrine response. Evolution has not provided our nervous and endocrine system with the ability to withstand a prolonged inflammation requiring artificial life support.

 

Macintyre. Chronic critical illness: the growing challenge to health care. Respir Care 2012;57(6):1021-7

Like many other papers on this subject it starts with an attempt to pin down a definition. The main part of the definition it works with is the presence of prolonged mechanical ventilation discussing the length of this PMV as being 21 days of mechanical ventilation whilst also acknowledging that it could be as little as 14 or as much as 28 days ventilation.

There is also the need to ensure that this population requires a different mindset to the acutely ill patient in ITU. Unlike the acutely ill patient the CCI patient is characterised by:

• slow fluctuations in function and care needs
• slow changing baseline which can be frequently interrupted by acute events

Caregivers with unique skills are needed and because outcomes are poor a culture of care that has a heavy palliative care influence is critical.

In general yearly mortality is 40-50%.

ProVent score:

• calculated at 21 days of mechanical ventilation
• age > 50yrs
• Platelets <150
• Need for vasopressors
• need for dialysis

If none of these factors present then survival was over 80%. However if all 4 were present there was virtually 100% mortality at one year.

CCI is a persistent ongoing inflammatory state following an initial inflammatory insult. There is persistent elevations of cytokines and a failure of anti inflammatory processes to modulate and repair.

Organ dysfunction may have left the patient with:

• heart failure
• liver failure
• adrenal failure
• neuromyopathies
• impaired cognition
• hormonal dysregulation and renal failure.

These can be combined with

inappropriate clinician responses such as:

• inadequate antibiotics
• inappropriate ventilator settings
• fluid overload
• electrolyte mismanagement
• malnutrition
• excessive sedation
• nosocomial infection risks

Discussion then moves onto the venues of care with proponents of the long-term acute care hospital (LTAC) arguing that the culture of care is more rehab oriented with an emphasis on physical therapy, occupational therapy and respiratory therapy that is better suited to the patients long term needs.

Issues of mechanical ventilation are covered. The injured lung has abnormal mechanics, abnormal dead space and impaired gas exchange that can overload the neuromuscular capabilities of the patient with CCI.

Ventilator settings should be lung protective and there is no clear consensus on how best to remove/reduce ventilator support in this population.

Spontaneous breathing trails should not be attempted until the support has been reduced to an appropriate level e.g. pressure support 10-15 cm, PEEP <5 and oxygen 0.5 or below.

In those patients with a tracheostomy care should be taken when decannulating the patient with secretion issues or obstructive apnoeas.

It is important to acknowledge that some patients will never be weaned off the ventilator- the literature indicates that 90% or more of those patients who eventually are weaned have the weaning complete by 90 days of mechanical ventilation.

Supportive evidence for NIV in CCI is lacking.

Nutritional support is important as many of the features of the CCI patient involve persistent catabolism, malnutrition and neuro-endocrine imbalance. Hypoglyceamia is a common problem as is bone resorption, vitamin B deficiency and anasarca. Bone dysfunction requires multiple strategies, including calcium replacement, vitamin D replacement and biphosphonates.

They are at increased risk of infections because of multiple invasive devices, malnutrition, hyperglyceamia and immune exhaustion.

Device associated infections can be limited by using appropriate care bundles. VAP would include head of bed elevation, minimised sedation, oral care, subglottic suctioning,peptic ulcer disease prophylaxis and DVT prophylaxis. Infection care bundles would include hand hygiene, complete barriers for central line insertion, chlorhexedine use, proper site selection and daily assessment for continued need of catheter.

Neuromyopathies commonly occur in the critically ill being both myopathys (direct muscle injury) and polyneuropathy (diffuse axonal injury) both secondary to impaired oxygen delivery/uptake. Prevention and management of this would include good glucose control, reduction of neuromuscular blockers and steroids, optimisation of electrolytes and early mobilisation.

Delirium should be managed taking care of the risk factors such as inflammation, hypotension, electrolyte shifts. sleep deprivation, hypoxeamia and drugs.

There should be a more palliative care mindset which focuses on symptom relief , align treatment of patient and family wishes and provision of patient and family support.

Maguire. Strategies to combat chronic critical illness. Curr Opin Crit Care 2013;19(5):480-7

This starts by attempting to define what is meant by CCI. Initially they say it is those who have survived acute critical illness or injury, but have a persistent organ dysfunction leading to prolonged intensive care needs. Many of the definitions include the need for prolonged mechanical ventilation (PMV) but the length of that seems to vary greatly from 96 hours to 21 days.

CCI is a syndrome which also includes profound weakness, malnutrition, anasarca (generalised oedema), prolonged brain dysfunction and extreme symptom burden. They feel that the presence of a tracheostomy might also make the patient inclusive in the CCI category, but they do conclude by saying that recognition is perhaps more important than any rigid definition.

Depending on the definition, of the mechanically ventilated patients in the ICU 5-10% develop CCI and this number is projected to double in the next ten years. Based upon some cohort studies one-year survival for CCI is between 40-50%.

The article then moves on to prevention and management of CCI and starts this by looking at mechanical ventilation. ARDS is most associated with CCI and some of the strategies concerned with this problem are highlighted. These include protective lung ventilation, conservative fluid management, sepsis bundles, daily awakening trials and spontaneous breathing trials.

With the spontaneous breathing trial (SBT) they go on to compare tracheostomy collar groups with the pressure support based weaning protocol. In a trial of patients those with the tracheostomy collar weaned in 15 days compared to 19 days with pressure support. They go on to say that the optimal approach to weaning is not necessarily clear but there should be a more aggressive search for the causes of failure.

ICU acquired weakness (ICUAW) is acknowledged as a well-recognised complication of critical illness. Perhaps one of the most interesting points in the paper and certainly one that should always be borne in mind is this;

In one study of patients requiring at least 28 days ventilation, neurophysiologic evidence of chronic partial denervation of muscle consistent with previous critical illness polyneuropathy can be found up to 5 years after ICU discharge in more than 90% of patients.

The risk factors which contribute to ICUAW include prolonged immobility, hyperglycaemia, systemic infection and multiple organ dysfunction. Possibly mitochondrial dysfunction, contributing to diaphragmatic weakness adds to the ICUAW and the role of systemic corticosteroids is unclear. One of the main recommendations under this heading is the early mobilisation of the patients being key to improving their outcomes.

Malnutrition is reported in 43% of ICU patients and this is associated with increased morbidity, mortality, infection rates, ICU length of stay, poor wound healing and muscle weakness. Data still supports the use of enteral feeding in those patients with a functioning GI tract.

Mean physical function and survival at 12 months in the ARDS patient were not affected by initial trophic versus full feed. The data is not conclusive when looking at adding parenteral to enteral feed but there is an observation that over feeding rather than underfeeding may be more common and this can lead to increased infectious complications, liver dysfunction and increased mortality.

Cognitive impairment is a feature of this type of patient and affects a large number of them one year after ICU and there is possibly some relationship between acute delirium and long-term impairment. The most important way to manage this is to evaluate for any modifiable cause such as infection, hypotension, electrolyte imbalance, hypoxia and the use of sedatives.

The ICU patients have a lot of invasive lines and some of the infections these produce may add to their potential to become a chronically critically ill patient. They speculate that 'immune exhaustion' is another mechanism that puts the patient at risk. So there should be basic infection control measures, a minimization of catheters and possibly decontamination using intranasal mupicirin and chlorhexedine cloths to reduce the incidence of MRSA.

It is also noted that the patient and family wishes should also play a major part in the care of the critically ill. There should be frequent discussions about this covering areas such as thresholds for continuation or discontinuation of therapies, open and honest communication about eventual location of discharge and preparedness planning for upcoming therapies.

The venue of care is also something which needs to be considered. Is it appropriate for this type of patient to be cared for in the acute ICU. We need to consider other centres which will particularly address their special needs.

In summary, there needs to be prevention measures including:

• EGDT
• Lung protective ventilation
• Daily awakening
• Spontaneous breathing trials
• Early mobilisation
• Prevention of infections

and then management strategies of the CCI which will include:

• Ventilator strategies
• Nutrition strategies
• Rehabilitation strategies.

Interview Questions for Advanced Critical Care Practitioners

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