I would like to introduce you all to Bryan Boling (@bryanboling) who is a critical care nurse practitioner over in the States. He is going to be a regular contributor to the podcast and he has many ideas and topics he wants to cover. In this episode, we talk about the differences and similarities of the practitioner role in the UK and USA.

I thought it was time we explored the subject of mechanical ventilation again and so I reached out on Twitter and am now joined by Thomas Piraino (@respresource) who is a Clinical Specialist in mechanical ventilation at the Centre of Excellence in Mechanical Ventilation, St. Michael’s Hospital.

We start with the basic modes and what is actually happening in those modes. You are going to have to concentrate on this one. Hopefully, this will be a series of podcasts to help us all understand better the process of mechanical ventilation.

I was lucky enough to be joined by Cath Edwards (@cathedwards_1), a physio up in Lancashire. She attended this years British Thoracic Society 2018 Summer meeting. So I picked her brains about what she heard there. It sounds like a great conference and I think one I will be trying to attend in the future. 

Interview Questions for Advanced Critical Care Practitioners

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In May of this year, the American Association of Critical Care Nurses held their National Teaching Institute & Critical Care Exposition.  NTI2018. By UK standards this is huge with over 9,500 delegates and 350 presentations to go to! I followed this conference via social media so kind of experienced it. I also watched the Facebook Livestreams they did at the end of each day and was lucky enough to get to chat with the three nurses involved in this: Jon (@technursejon), Marissa (@marissa_labate) and Anna (@anna_the_nurse). Lots of great things happened there and I hope I might be able to be there in person next year.

 

Extracorporeal membrane oxygenation or ECMO is one of those treatments we sometimes need to think about with our very sick patients. I recently had to make a referral to my local centre and doing so made me wonder what it is that the ECMO centres want from us to make the path smoother. So I asked Dr Susan Dashey, Consultant at Glenfield Hospital and Dr Brij Patel, Consultant at the Royal Brompton and Harefield Hospitals. Both these are centres for ECMO.

I think their answers will provide us with some guidance for the future.

The psychology of our patients, their relatives and the staff we work with is under discussion in this podcast. I managed to get Megan Hosey (@DrMeganHoseyPhD), a psychologist from Johns Hopkins, Dr Julie Highfield (@DrJulie_H), a psychologist from Cardiff and Dorothy Wade (@dwadepsych) a psychologist from London together to discuss these important issues.

We talk about management issues to help prevent PTSD and how we can identify and manage burnout in staff.

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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Gavin Denton and I get together again to review a couple of recent papers that have some bearing on our practice.

This month we cover Check Up- Position- "A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults" and the APRV trial -BILEVEL-APRV 

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.
• Unblinded.
• 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.

• Adults.
• 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 85.4% 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.

 

APRV trial -BILEVEL-APRV 

 

 

In 2017 Zhou et al published a trial called “Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome.”

In order to understand the trial and the results lets first be clear about what is APRV or Airway Pressure Release Ventilation and its basis on the principle of open lung ventilation. Open-lung ventilation refers to the concept of recruiting the lung and then ventilating gently with small tidal volumes, to avoid either over-distension or atelectotrauma (lung damage from cyclical opening/closing of alveoli).

 

Two levels of PEEP: high (P-high) and low (P-low)

patient breaths spontaneously during P-high and P-low

time in P-high (T-high) is longer than P-low (T-low) to maintain recruitment (85-95%)

results in a degree of autoPEEP due to the short release time (T-low)

 

Advantages

alveolar recruitment and improved oxygenation

preservation of spontaneous breathing

reduction of left ventricular transmural pressure and therefore reduction of left ventricular afterload

potential lung-protective effect

better ventilation of dependent areas

lower sedation requirements to allow spontaneous breathing

 

Disadvantages

risks of volutrauma from increased transpulmonary pressure

increased work of breathing due to spontaneous breathing

increased energy expenditure due to spontaneous breathing

worsening of air leaks (bronchopleural fistula)

Increased right ventricular afterload, worsening of pulmonary hypertension

Reduction of right ventricular venous return: may worsen intracranial hypertension, may worsen cardiac output in hypovolemia

Risk of dynamic hyperinflation

 

There have been animal studies demonstrating that APRV can increase alveolar recruitment gas exchange and therefore reducing lung injury.

The ARDSnet trial established that mechanical ventilation at a six mls per kilo set tidal volume was superior to 12 mls per kilo in patients meeting criteria for ARDS. Several studies since have demonstrated that this target is often not adhered to.

 

The comment in Rob McSweeney’s review is that the use of APRV in patients with ARDS has been led by enthusiasm rather than rigorous evidence of benefit.

As Jonny points out here, ARDS is an inflammatory process leading to increased lung vascular permeability which further leads on to hypoxaemia and reduced lung compliance. As a consequence we tend to ventilate this type of patient with low tidal volume ventilation.

 

The aim of this study therefore was to establish whether the use of APRV will reduce the duration of mechanical ventilation versus low tidal volume ventilation.

So this was a single centre, randomised controlled trial comparing APRV against low tidal volume lung protective ventilation in patients with ARDS conducted in China. Eligible patients were having mechanical ventilation for greater than 48 hours and met the Berlin diagnostic criteria for ARDS.

Amongst the exclusions were those with relative contraindications to APRV including those with barotrauma, severe chronic obstructive pulmonary disease and intracranial hypertension.

You can see from Johnny’s info graphic the settings here in the intervention arm and the primary outcome to be measured was the number of ventilator free days up to date 28.

Secondary endpoints included clinical outcomes (including mortality) and respiratory mechanics.

Overall over 16 months 138 patients were enrolled. Raised intracranial pressure and unexpected early extubation were the commonest exclusion reasons.

So patients in the APRV group had significantly more ventilator free days by day 28 than those in the low tidal volume group-  p value 0.001 more patients receiving APRV were successfully extirpated and fewer required tracking ostomy.

Neuromuscular blockade, prone positioning, nitric oxide or high frequency oscillators ventilation was required in 34% of patients in the low tidal ventilation arm and 8% of patients receiving APRV.

Length of stay was significantly reduced in ICU but not in hospital stay. Intensive care unit mortality and hospital mortality were not significantly reduced with APRV.

At day three patients receiving APRV had significantly lowerFiO2 and higher mean airway pressures and pAO2.

Patients receiving APRV also had a lower mean heart rate and higher mean arterial pressure.

Finally at day three and a seven APRV patients were less sedated by RASS scoring and receiving less sedatives by infusion.

 

Whilst these results also and very encouraging there are a number of problems with this study which should lead us to view the results with care.

Firstly this was a single centre study with relatively small numbers which could mean that rare, but serious adverse events of either therapy may have been missed.

 

The trial was conducted in China which may lead to differences in both the patient population and the type of health care system to that found in the West. Due to the nature of the trial those treating the patients were unblinded to the treatment allocation which could raise a possible bias.

 

Tidal volumes of up to 8 mills per kilo were allowed in the low tidal volume ventilation group. This is higher than that recommended in the ARDSnet trial.

The P low was also set to 5 cm whereas a P low of zero is more commonly advocated.

So due to some of these issues and the fact that the results from this study are not in agreement with previous randomised studies, which have found in the past that APRV leads to increased time to extubation, and also having shown improved outcomes with low tidal volume ventilation in ARDS it is felt that repetition of this study in a large multicentre setting would be advisable.

 

Links

Emcrit- https://emcrit.org/pulmcrit/aprv/

Life in the Fast Lane- https://lifeinthefastlane.com/ccc/airway-pressure-release-ventilation-aprv/

 

 

 

Interview Questions for Advanced Critical Care Practitioners

 

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ACCPs skills are many and varied as those of you who do the job will know. My friend Gavin Denton (@DentonGavin) has conducted 3 different audits along with his colleagues at the Heart of England NHS trust. In this podcast he presents some of the very interesting findings.

I think it proves that we are very worth the time and investment in developing our roles and that we will prove to be a very valuable, if not essential part of the workforce in the future.

The Intensive Care Society, Faculty of Intensive Care Medicine, Difficult Airway Society and the Royal College of Anaesthetists have combined to provide the 'Guidelines for the management of tracheal intubation in critically ill adults'. The main part of the document covers Plan A to Plan D when performing this procedure. This is well worth a read and in this podcast, I go through the various stages and what they recommend.

This is a conversation I had with Marcus Peck (@ICUltrasonica) who is the chair of the FICE committee (Focussed Intensive Care Echocardiography) and Hannah Conway who is an ACCP at Glenfield Hospital and is VERY qualified when it comes to ultrasound and echocardiography.

It would seem that Marcus and colleagues are very keen for us to do echo! So lets do it!

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

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

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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

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.

 

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.

Thank you.

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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.

Thank you.

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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

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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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.

Thank you.

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Simple- My take of DasSMACC Day 3!

Interview Questions for Advanced Critical Care Practitioners

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

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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.

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.

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

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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

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

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

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

Some of the studies in the debate :

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

A national survey of intensive care follow-up clinics

One year outcomes in caregivers of Critically Ill Patients

The Recover Trial

Improving outcomes after critical illness: harder than we thought!

Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis

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

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

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

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

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

 

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

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

Clinical question.

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

 

Design.

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

 

Setting.

Elective neurosurgery.

 

Population.

Elective patients in two South Korean hospitals.

 

Intervention/control.

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

 

Outcome.

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

 

Author’s conclusion.

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

 

Strengths.

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

 

Weaknesses.

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

 

Bottom line.

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

 

Links.

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

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

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

LIFTL- Rapid Sequence Induction

Rapid Sequence Intubation: Medications, dosages, and recommendations

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

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

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

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

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

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

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

The Insomnia Severity Index

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

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

Cochrane Database Syst Rev. 2015 Oct

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

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

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

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

Why Won't My Patient Sleep!

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

Stages of sleep

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

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

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

What happens during sleep?

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

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

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

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

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

Sleep in ICU

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

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

Causes of sleep disruption.

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

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

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

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

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

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

Psychological consequences of sleep deprivation in critically ill patients.

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

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

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

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

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

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

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

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

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

How high should I sit my patient?

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

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

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

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

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podcast.

Just a quick one to wish you all a happy christmas...thats all!

Dorothy Wade works as a chartered health psychologist in the Critical Care Unit at UCH. She is registered as a practitioner psychologist with the Health and Care Professions Council, and has a PhD in psychology and health care evaluation from University College London. She is available to support patients, families and staff in Critical Care.

PTSD

Post traumatic stress disorder is defined as a condition of:

• persistent mental and emotional stress
• occurring as a result of injury or severe psychological shock
• typically involving disturbance of sleep and constant vivid recall of the experience
• with dulled responses to others and to the outside world.

and its something the critical care patient can experience after discharge from the department. Dorothy and I discuss many of the issues involved and some of the things we can do to help minimise this problem.

ICONStudy

Intrusive memories of hallucinations and delusions in traumatized intensive care patients: An interview study.

What explains the prevalence of post traumatic stress disorder, depression, anxiety and poor quality of life after intensive care?

Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study

Identifying clinical and acute psychological risk factors for PTSD after critical care: a systematic review.

This episode features a chat with Fiona Moffat who is a lecturer in Physiotherapy and practising physiotherapist. She was involved in some LEAN thinking and is now interested in early mobilisation in the critical care world. As a social scientist she is also interested in how we get to normalise new technologies or interventions in health care and what are the barriers to those interventions.

She is presenting at the ICS State of the Art conference 2015 and so it was interesting to get to chat to her about some of the issues.

Demystifying theory and its use in improvement Davidoff et al.

Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Carol Hodgson et al

Normalisation Process Theory- Carl May

Motomed- physical training in bed!

TEAM is a program of research to evaluate the effect of early mobilisation to assess functional recovery and patient-centered outcomes of ICU survivors. Carol Hodgson is one of the lead clinicians in this project, She will be presenting at the 2015 Intensive Care Society State of the Art conference, so this is an opportunity to hear some of the areas she is concerned with.

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study.

TEAM Studies Website

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Schweickert, W. et al The Lancet. Vol. 373, No. 9678, p1874–1882, 30 May 2009

Physiotherapy in the Intensive Care Unit Netherlands Journal of Critical Care 2011

Cycle Ergometry

Early rehabilitation in critical care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial.  Parry, S. et al. BMJ 2012

Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist Mendez-Tellez et al,  Neurohospitalist. 2012.

Characterization of the use of a cycle ergometer to assist in the physical therapy treatment of critically ill patients Pires-Neto et al. Rev Bras Ter Intensiva. 2013

Myself and Tracey Starkey-Moore (@TraceyStarkeyMo) led a @WeNurses chat on the 1st October about Advanced Practitioners. You can find the Summary on the discussion on the WeCommunities website with the relevant key word clouds.

Tracey and I then got together with Gavin Denton (@DentonGavin) and Jemma Owen (@JemmaOwen1) to discuss some of the key issues that came up on the night. I think we highlight some interesting issues in the development of Advanced Practice

RCN Guidelines on Advanced Nurse Practitioners

The role of advanced nurse practitioners.

Development of Advanced Care Practitioners in Emergency Services

The National Education and Competence Framework for Advanced Critical Care Practitioners.

Royal College of Emergency Medicine Curriculum for Emergency Care Practitioners

DoH Advanced Level Nursing- A position statement.

Nursing Times- Understanding Advanced Nursing Practice

In this episode I talked to Jennifer Cotton (@sonomojo) who runs the website Sonomojo which is a guide to ultrasound education and she talks about her reasons for setting up the site. The aim of the site is about connecting people to resources about ultrasound.

Jennifer is just about to become a doctor and has worked with colleagues such as Matt Dawson from the www.ultrasoundpodcast.com website as part of her training to become more competent at this skill.

She also promotes the Ultrasound Interest Groups (USIG) which is way of developing groups that can focus on student organised, faculty led workshops.

http://sonomojo.org/

http://www.ultrasoundpodcast.com/

National USIG

http://emcrit.org/rush-exam/

How to Case Study: RUSH Exam Video Part 1 - SonoSite

Lynn Schallom is a research scientist at the Barnes-Jewish Hospital in St. Louis. She published a paper 'Head of Bed Elevation and Early Outcomes of Gastric Reflux, Aspiration, and Pressure Ulcers' in the American Journal of Critical Care in January 2015.

Head of Bed Elevation

There is a conflict between the need to keep a patients head elevated to reduce the incidence of oesophageal reflux and consequent pneumonia, and the prevention of pressure ulcers. Can we do both? In her very small study Lynn seems to show that head of bed elevation is important and that we can. She also highlights some other areas of concern, one of which is the use of the trendelenberg position when sliding patients up the bed. This would seem to put patients at increased risk of aspiration as their secretions are encouraged to run in the 'wrong' direction!

"Have you ever wanted the speaker to fail?"

In this episode of the podcast I speak with Dr Ross Fisher (@ffolliet) about presentation skills. Many of us have sat through 'death by powerpoint' and have come away non the wiser afterwards. Having watched a lot of TED talks I can testify that a good presentation can make a massive difference to what you learn and whether you will be back for more.

Ross tells us some very simple techniques to help us improve the way we put our message across. I think you will find a lot of useful pointers.

I include below some of the books that we mention as well. I have read them all and I can highly recommend them.

You can find Ross's website at prezentationskills.blogspot.co.uk/

Break for Summer Holidays!

In this podcast I carry on my conversation with Ollie Poole (@respreview) about some of the issues with mechanical ventilation. We talk about the different types of breath and why we use them. This then helps us identify some of the very confusing terms the ventilator companies use when describing their ventilator modes.

We somehow manage to bring some puppies into the conversation too!! If you want more from Ollie then go to his fantastic YouTube site where he covers other subjects too.

Thyroid Storm Chapter: Review of Diagnosis and Treatment of Thyroid Storm - emcrit http://t.co/v8qQMMZh35 #FOAMed

— foambase (@foambase) May 17, 2015

Thyroid Storm

Dr Scott Weingart (@emcrit) does his usual brilliant job over at EMCRIT explaining some of the issues in this condition. This is one I have encountered in ITU so I found particularly interesting.

 

 

 

Are you an Advanced Practitioner in any specialty? Then you need to come to this meeting. This is the 3rd year this has been held in Coventry and gives us all a chance to network. Also priced very reasonably so you have no excuses. 

Some good speakers lined up talking about:

An Analysis of UK wide advanced practice programmes.

Advancing Nursing in gerontology.

Challenges of Advanced Practice across primary and secondary care.

In the afternoon there are going to be chances to have a chance to review your anatomy of various systems using the state of the the art Surgical Training centre, followed by workshops in writing a publication, presenting a business case and undertaking research.

Come along and help mold the changes we are all making.

 

Wendy Sinclair (@wlasinclair) is a lecturer in childrens nursing at Salford University and has been there for the last eight years. She started using Twitter about a year ago as a way of engaging the Salford Nursing Students. Also to see how they could use social media in both a professional and social capacity. She is also working towards a PhD in Social Media and Professional Conduct.

We are also joined by Neil Withnell (@neilwithnell) is a senior lecturer in mental health nursing and Moira McCoughlin (@levylass) who is a childrens nurse and senior lecturer.

An interesting discussion is had by us all about the benefits of social media when used well and the empowering of their students. This is a model that others should follow.

I also want to point out a conference which is happening in Coventry in July. This is the 3rd National Advanced Practitioner conference. You can click on the image below for a link to the application form.

This is not an expensive day and it would be great to be able to network with other practitioners. I am pushing people to go from my trust, so lets all the do the same. See if we can overwhelm them with interest. I am hoping that I will be able to let you all know the format of the day by the 11th May. So watch out for my tweets!

#FOAMed has been helpful as always. Salim Rezaie has put together a great post about Seepsis and some of the current practices, along with a podcast and his slides which he used at a recent conference. Click on the copy of the tweet below from @drwillangus.

ICYMI: Sepsis Care in 2015 -> Sepsis Trilogy, Goal MAP, Hb transfusion, & more http://t.co/KQoni3s8Iu #FOAMed #FOAMcc pic.twitter.com/0zZNPi1pJS

— Salim R. Rezaie (@srrezaie) May 6, 2015

I am also tweeting like fury about this years Intensive Care State of the Art meeting in December of this year. Its going to be a good one I think and I hope to be well involved on the social media side of things via @ganesh_ICM who is doing a fabulous job of putting things together.  Click on the tweet below to see what he is up to, and please retweet if when you see it! 

Go to http://t.co/KrRBCgdWtL live now! To register for this years ICS State of the Art conference. #icssoa2015 pic.twitter.com/U8kc4lQbnd — Jonathan Downham (@ccpractitioner) May 6, 2015

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Kirsten Kingma (@surferkirst) is currently a medical student who started her health care career as a paramedic

We start by talking about the role of the paramedic in South Africa and how the different funding system impacts upon health care.

We also talk about the medical staffing issues in South Africa and then finish up agreeing about how wonderful Twitter and FOAMed is for the ambitious practitioner.

I think I may have persuaded her to come back for more in the future as my South Africa correspondent!

FOAMed

A Randomized Trial on Subject Tolerance and the Adverse Effects Associated With Higher- versus Lower-Flow Oxygen Through a Standard Nasal Cannula

Another article has been highlighted via twitter which further advances the cause for the practice of NODESAT or the use of nasal oxygen during rapid sequence induction. This is a simple thing to do for the patient and it has been shown to be effective and not uncomfortable for the patient:

Use of High-Flow Nasal Cannula Oxygen Therapy to Prevent Desaturation During Tracheal Intubation of Intensive Care Patients With Mild-to-Moderate Hypoxemia Miguel-Montanes, R., Hajage, D., Messika, J., Bertrand, F., Gaudry, S., Rafat, C., … Ricard, J.-D. (2014). . Critical Care Medicine

Apneic oxygenation via nasal prongs at 10 L/min prevents hypoxemia during tracheal intubation for elective surgery. Christodoulou, C., Rohald, P., Mullen, T., Tran, T., Hiebert, B., Lee, T., & Sharma, S. (2013).  Eur. Respir. J.

A Randomized Trial on Subject Tolerance and the Adverse Effects Associated With Higher- versus Lower-Flow Oxygen Through a Standard Nasal Cannula. Brainard, A., Chuang, D., Zeng, I., & Larkin, G. L. (2015). . Annals of Emergency Medicine, .2014.10.023

Evidence Based Preoxygenation from Rob from ercast on Vimeo.

 

Osler

I had a very interesting conversation with one of my Twitter contacts last week, Dr Todd Fraser (@Sunnydoc72). He has become concerned over the years that health care professionals seem to have no consistency over the benchmarking and recording of their skills. As a consequence he has started a crowdfunding campaign to try to get the necessary finance together to produce.

Osler is a digital technology that will allow you to benchmark your performance against others in a similar position providing you a report card of procedural and clinical capability. There will be access to a learning platform with multimedia, interactive and patient focused learning resources. You can keep up to date with the latest literature and Osler Knowledge will give access to a database of latest research, which it will search for you depending on the question you ask.

You will also be able to connect with your peers to help you understand difficulties you maybe having. There will be an authentication process throughout all of this so that you can be sure that the information you get is reliable and the people you are interacting with are trustworthy.

The crowd funding process asks that you make a financial promise. It aims to reach a target of $300,00 within 30 days. You can pledge as little as $10 all the way up to $5000. This money will not be taken from you until the target is reached. If you pledge then there are some incentives offered.

I think this looks like a fantastic idea, but will need some support to get it off the ground. Todd has clearly worked very hard at this and is very passionate. Worth a few dollars I think.

 

PLEASE go to www.life-saver.org.uk to see the fantastic job this podcasts interviewee has done of making the teaching of basic life support so much easier. I was blown away when I came across it, even as an experienced ALS team member.

It sucks you in and gets you involved. To the novice it is a wonderful learning resource, to the experienced it is great revision.

Martin Percy was the director and we talk about some of the barriers he came up against when raising the funding and one or two great stories that came about. One of those stories gives this episode its title!

#FOAMed

The results of the PROMISE trial are out and rather than redo what everyone else has already done I will just point you in the direction of my colleague Simon Laing (@laing_simon) who has summarised it nicely on the HEFTEMCAST podcast.

I will also quote from Steve Mathieu (@stevermathieu75) on The Bottom Line:

"Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous SCVO₂ measurement and CVP to guide management. Perhaps we should not completely dismiss the term 'EGDT'. Afterall,  our 'usual care' consists of early intervention and goal directed therapy. The goal... to continue to reduce mortality with high standard and consistent quality care."

A point I seem to remember making on a podcast with the ARISE trial authors some months ago.

The guys over at FOAMCast have just released a podcast that tries to explain some of the confusing research terms. If you are like me, then any research term can become confusing. This is a good episode and I am hoping that they will add more in the future.

Antibiotic sensitivity spectra is the focus of a tweet by Pietro Isotti, (@pietroisotti)  a nursing student in Italy. This is a nice PDF of the range of sensitivities and the antibiotics used. 

This podcast is a discussion with one of the main organisers of the SMACC event later this year, Oli Flower (@OliFlower). The conference is looming fast, in June of this year in Chicago. We discuss the past conferences and the ethos behind them and the upcoming one.

Oli is also involved with the Intensive Care Network website.

There is also a mention of two other podcasts in the episode, Jesse's (@Inject_orange) Injectable Orange podcast and Brians (@erNURSEpro) ER Nurse Pro podcast. Both excellent giving some different perspectives.

The third in the series with Ollie Poole (@RespReview) on mechanical ventilation. Ollie goes into some more detail on the phases of the breath. This requires some visualisation of the waveform involved. Below is the video from YouTube that Ollie originally produced which should help with that.

Irma Bilgrami does a great job of breaking down some of the principles of mechanical ventilation in her SMACC talk. She approaches it in a similar way to analysing the ECG waveform.

#FOAMed

Delayed Sequence Intubation-

DSI in pts requiring intubation & NOT tolerating preox or peri-intubation procedures http://t.co/vCZX2e10hL #FOAMed pic.twitter.com/3G5MvLiKv7

— Salim R. Rezaie (@srrezaie) February 24, 2015

A new study in Annals of Emergency Medicine seems to support the process of delayed sequence intubation in those patients that will not tolerate pre-oxygneation or peri intubation procedures. EmCrit has a nice algorithm on his site (he was involved in this study) which breaks the process down simply and The Bottom Line has reviewed the paper in question. Scott has also done is usual great job in helping us understand this through his podcast:

Life in the Fast Lane breaks the process down in some more detail.

Cervical Collars-

"CERVICAL COLLARS SLASHED FROM GUIDELINES |" http://t.co/jLcPZVCxca #FOAMed Not just any guidelines - ILCOR guidelines!! This is huge! — UNM Wilderness Med (@UNM_WildMed) February 12, 2015

ILCOR (International Liaison Committee on Resuscitation) have published some draft guidelines on the use of cervical collars which does not recommend their use. Scancrit covers some of this in his blog and, like him, I will quote what they actually say:

"We suggest against spinal motion restriction, defined as the reduction of or limitation of cervical spinal movement, by routine application of a cervical collar or bilateral sandbags (joined with 3-inch-wide cloth tape across the forehead) in comparison to no cervical spine restriction in adults and children with blunt suspected traumatic cervical spinal injury (weak recommendation, very low quality of evidence).
Values and preferences statement: Because of proven adverse effects in studies with injured patients, and evidence concerning a decrease in head movement only comes from studies with cadavers or healthy volunteers, benefits do not outweigh harms, and routine application of cervical collars is not recommended."

Intensive Care Society State of the Art Meeting December 2015

An interesting early steer from @icsmeetings #icssoa2015 consultation. Add your views! http://t.co/nRdSk0a5KN pic.twitter.com/k56pOT6W3a

— GaneshSuntharalingam (@Ganesh_ICM) February 15, 2015

I have had the recent privilege of being introduced to Ganesh Suntharalingam (@Ganesh_ICM) who is involved in the committee with the Intensive Care Society for the State of the Art meeting later this year. He is gathering a team around him who will help make some changes to the format of this excellent conference. He tweeted some results from a survey he published which makes some very interesting reading. What I found exciting is that others feel, like me, that publication of some of the presentations for those not able to attend would be valuable. This is the FOAMed principle in practice. You can continue to add your own views via this link. Advanced Critical Care Practitioner Conference-

3rd National ACCP conference 3rd July hosted by FICM @ RCoA only £40. Save the date !@accpuk @ccpractitioner — CAROLE BOULANGER (@BOULANGERCAROLE) February 16, 2015

Conference details can be found here.

I love the world of social media. It was through the medium of Twitter that I was able to connect with James DuCanto (@jducanto)who is an anesthesiologist at Aurora Health Care in Wisconsin. Gavin Denton (@DentonGavin) and I picked his brains about some of the pitfalls in intubation especially for those not so experienced but who may well still find them in a situation where they may have to perform the task.

James has produced a few teaching videos around some of his ideas, some of which you can see on Minh LeCongs (@ketaminh) PHARM site, so I won't reproduce them here. just follow the link.

I did ask him about cricoid pressure and his answer was interesting. If you want to hear the discussion I had with Minh about this then go listen to CCP Podcast 010.

Society for Airway Management

Life Form Airway Simulation Trainer

Air Q Laryngeal Mask

Laerdal Difficult Airway Trainer

Glidescope Titanium Video Laryngoscope.

AIRWAY ASSESSMENT : PREDICTORS OF DIFFICULT AIRWAY

Difficult Airway Society

CCP Podcast 026 was myself and Ken Spearpoint (@K_G_Spearpoint) talking about some of the issues around Crew resource Management. we continue the conversation in this episode and maybe even arrive at some conclusions....maybe!!

Ken Spearpoint and I talk about Crew resource management as it relates to the cardiac arrest scenario. I love talking with Ken as he is so knowledgeable and puts his points across so well. i found it really interesting to chat with him about this. I have broken it down into two parts as we both had so much to say, so the second part will be podcast 027 next time.

 

I am lucky enough to get to chat to Teresa Chinn from @WeNurses. I first spoke with Teresa on my very first podcast and since then we have both grown our various enterprises.

Teresa has been awarded an MBE in the New Years honours list this year and it is thoroughly deserved for all her services to nursing.

We talk about her visit to Parliament and to the Health Select Committee. An informal process she said, but it sounded much more than that.

She also talked about how the website is developing so that they can use all of the information they are collecting and use it more effectively.

WeNurses Pinterest.

WeNurses Vimeo

WeNurses Facebook

This is the second of a series of podcasts with Ollie Poole who was a respiratory therapist in Canada and is now doing his medical training. You can listen to the first episode if you wish... CCP Podcast 018: Mechanical Ventilation....

We go back to some of the basics here, discussing some of the reasons and goals of mechanical ventilation.

I came across Ollies' YouTube site Respiratory Review and was very impressed with his series on mechanical ventilation helping to explain some of the terminology and reasoning behind how we ventilate patients. He breaks down the issues in a logical, well ordered format....so go and listen to them.

Our plan is to have a series of chats about mechanical ventilation based around his YouTube videos, so watch this space!

Reducing ventilator associated pneumonia in adult patients through high standards of oral care: A historical control study

Lee Cutler, Paula Sluman. Intensive and Critical care Nursing. 2014

Consultant Nurse Lee Cutler discusses the study he was involved in with his colleague Paula Sluman. Ventilator associated pneumonia is a big problem in the critical care environment so it is very important that we take all the measures we can do reduce its incidence. This seems like a simple approach which makes a difference.

Shiela Pantrini has been developing the educational route for the Advanced Clinical Practitioners along side Garry Swann at the Heart of England NHS Trust. She tells us how this occurred and the principles that drove it. We also go on to discuss the plans for the future and what would make a good potential practitioner.

Two of the courses which contribute to the Masters programme were mentioned and the links for them are here:

Warwick University- Clinical Examination Skills for Health Care Professionals

Warwick University- Clinical Investigations and Diagnostics for Health Care Professionals

Happy Christmas all! A usurper takes the reins in this episode which allows Jonathan to talk about himself. Hope thats not too narcissistic! 

Some old guests make an appearance as well. Hope you enjoy it and Have a great Christmas.

Garry Swann returns to talk about the propsed imminent changes that will mean more practitioners across specialties making a difference to patient flow.

Garry first spoke to us in episode 015 and this is a continuation of that chat with some very important updates.

In an attempt to further my understanding of some of the methods used in research Gavin Denton (@dentongavin) and I had a discussion about the SepsisPAM trial below. This is a new approach on the podcast and one which I hope people will find useful. We go through the article using a systematic approach, and you can find the links to the CASP tool we use here. We also refer to CEBM.net here. We also try to stop to discuss any terminology which we were not too familiar with or needs clarification to help others understand it.

We would be really grateful for any feedback to let us know what you think.

Could we do it differently? A different format? Let me know via the speak pipe link to the side of this page.

High versus Low Blood-Pressure Target in Patients with Septic Shock

Pierre Asfar, M.D., Ph.D., Ferhat Meziani, M.D., Ph.D., Jean-François Hamel, M.D., Fabien Grelon, M.D., Bruno Megarbane, M.D., Ph.D., Nadia Anguel, M.D., Jean-Paul Mira, M.D., Ph.D., Pierre-François Dequin, M.D., Ph.D., Soizic Gergaud, M.D., Nicolas Weiss, M.D., Ph.D., François Legay, M.D.,

N Engl J Med 2014; 370:1583-1593April 24, 2014DOI: 10.1056/NEJMoa1312173

In this podcast episode I was lucky enough to have a discussion with Ollie Poole who is a respiratory therapist in Canada. 

I came across Ollies' YouTube site Respiratory Review and was very impressed with his series on mechanical ventilation helping to explain some of the terminology and reasoning behind how we ventilate patients. He breaks down the issues in a logical, well ordered format....so go and listen to them.

Our plan is to have a series of chats about mechanical ventilation based around his YouTube v ideos, so watch this space!

SMACC US programme is now out and it looks fabulous! A great variety of subjects over 3 days. I think the biggest problem will be deciding which lectures to go to. I am hoping to have a chat with Oli Flower in the future to discuss some of their plans.

The History Taking and Clinical Examination course I ran in Walsall went very well in September, and we have now booked another one 23-25th Febraury 2015. If you want to come along and join us then please do.

If you found this teaching about mechanical ventilation useful then let me know? Should we do more or less of this kind of thing. I want to be able to provide useful things to my audience so would be grateful for the feedback.

Simon Cooper is an Associate Professor at Monash University in Australia and developed the First2Act website which looks at the management of the deteriorating patient using multi media teaching tools.

I have been an advocate of using YouTube for many years now and one of the YouTube resources I have used for a while now is that created by Dr Eric Strong. I love his style and he teaches a lot of subjects which I encounter in critical and emergency care.

People often ask me which book they should read around various subjects and instead of pointing them to books I direct them to YouTube. If you find the right teacher, the visual element and voice over provided by YouTube I believe is a much better way to learn.

There are many more YouTube learning resources:

Andrew Wolf is an Assistant Professor & the Coordinator for Online Education at the University of Rochester School of Nursing. In addition to teaching physiology and pathophysiology, Andrew works as an acute care nurse practitioner for a general surgery service. His past clinical experience includes thoracic surgery, surgical intensive care, and oncology.

Armando Hasudungan  "I am not a doctor or professor, I am a student. I make these videos cause I enjoy art and science. Im not saying im 100% correct in all my videos. But I do try to obtain the information from credible sources."

Bozeman Science "Paul Andersen teaches science at Bozeman High School in Bozeman, MT. He is the 2011 Montana Teacher of the Year."

Handwritten Tutorials is a source of entirely FREE easy-to-understand medical tutorials

Interactive Biology "Many People struggle with Biology. I try to make it EASIER and FUN"

KhanAcademymedicine " Our mission is to provide a world-class education for anyone, anywhere. This channel includes Khan Academy videos on Medicine, presented by Rishi Desai, MD. All Khan Academy content is available for free at www.khanacademy.org."

MedCram "  Medical Topics Explained Clearly by World-Class Instructors. Free medical lectures for health care professionals and students. Review for USMLE, MCAT, PANCE, NCLEX, NAPLEX, NDBE, school and board examinations. SPEAKER: Roger Seheult, MD Clinical and Exam Preparation Instructor. Board Certified in Internal Medicine, Pulmonology, Critical Care, and Sleep Medicine.

Respiratory Review "These videos will cover many areas of respiratory care including: Gas Exchange at the Alveoli, Principles of Mechanical Ventilation, ABG interpretation, Pulmonary Function Testing and hopefully many more. I am a Registered Respiratory Therapist (RRT) working in Halifax NS, Canada. I'm also part of a critical care research team in Halifax, and have published my own papers as well." 

Terry Shaneyfelt 

"These are my videos about

1) Evidence based medicine

2) Perioperative evaluation and management

3) Teaching"

 

I hope you love these YouTube videos as much as I do. if you know any others then get in touch and let me know.....

This is a discussion with Garry Swann. Garry is the Consultant nurse lead in the Emergency Department at the Heart of England NHS Trust and is one of the main driving forces behind the development of the Advanced Clinical Practitioner roles at this trust. 

I made contact with Dr Segun Olunsanya via Twitter to discuss some of the issues around the fluid management of the sick patient. He in turn persuaded a couple of others involved in ITU. This has led to this fascinating discussion around this issue and it is one of the podcasts I am most pleased with.

A chat with Dr Louise Rose about her work in a weaning centre for the long term ventialted patient.

ICU-Acquired Weakness and recovery from Critical Illness. N Engl J Med 370;17 nejm.org april 24, 2014

An interview with Dr John Kress, an ITU physician from the University of Chicago. Dr Kress is a highly respected and well published doctor with an interest in ICU acquired weakness, one of his more well known papers being " Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation" which discussed the use of sedation breaks in the critically ill patients in intensive care.

Dr Kress very kindly agreed to help me understand some of the principles involved in this paper.

Another busy time in the world of the Critical Care Practitioner! This episode focuses on a discussion I had with Kaye Rolls (@Kaye_rolls) Clinical Nurse Consultant at the Intensive Care Coordination & Monitoring Unit (ICCMU).

She and I had a Twitter discussion around a couple of articles she had read about the use of social media by health care professions.

The first was "Social media: the way forward or a waste of time for physicians?" J R Coll Physicians Edinb 2013; 43:318–22. This is an article in two parts giving opposite sides of the argument. Both Kaye and I certainly disagree with one of them!

The second article was "Twelve tips for using social media as a medical educator" Medical Educator 2014; 36: 284–290 which offers a number of hints for making the most of this valuable resource.

The recent Celebration Day Jam
by many involved in the NHS Change Day was a webinar led by Helen Bevan, a lady I am hoping to speak to in the near future. This was a fabulous day and very interesting...its the way of the future!

Should we still be doing cricoid pressure? There are some very strong opinions out there. Minh Le Cong was kind enough to join me to discuss this important issue and we sort of arrived at a conclusion!

I get a chance to speak to some of those who were at SMACC Gold and also to Chris Nickson one of the organisers.

Claire Flatt is a staff nurse at the Heart of England NHS Trust. Sge shares her passion for nursing and describes her role as a Caremaker and an RCN Committee member

Bethan Bishop is Head of Innovation and Industry Engagement at the Heart of England NHS Trust in Birmingham. In this podcast she discusses how this role came about, having come from a background in the Pharmaceutical industry.

She works as part of the MIDRU team which aims to help in the innovation process. She is also involved with the Birmingham Science City initiative which is a partnership of public, private and HE sectors that aims to develop, use and promote science, technology to stimulate innovation to improve economic prosperity and quality of life.

There is a mention of the document "Innovation Health and Wealth" an important government paper and of the Academic Health Science Networks.

Bethan is obviously very passionate about her role in her Trust and working in partnership with others both within and outside the NHS will help make a difference to the ways we work.

Chat with David Barton Head of Department of Nursing at Swansea University. Discussion around the development and the roles of the Advanced Practitioners and his role in strategic planning of the future for the roles.

In this episode Critical care Practitioner chats with Ken Spearpoint, Consultant Nurse in Critical care and lead in a Masters degree in Medical Simulation. We also go onto to talk about the whys and wherefores of medical simulation.

In this episode I discuss all the other medical podcasts I listen to such as EmCrit, Parma and EmBase to name a few. Clips are provided of each one to give the listener a brief taster and clickable links can be found in the show notes for the episode.