State of the Art 2018
Day 3


The tour continues. Although I admit it took me a bit longer to get out of bed this morning following the social agenda for the conference….

Day 3: Morning

Another top 5 papers session covering infectious disease, trauma and cardiac research. Great stuff and well presented by all 3 speakers. There was even some emoji based learning which was new to me, but I suspect the kids are all over it. As yesterday, lots of good stuff and far too much to dig deep into here, but the papers are presented below. Remember to check out the short paper summaries at www.thebottomline.org, stemlynsblog.org and lifeinthefastlane.com. 

Infectious disease:

  1. Resuscitation protocol use in Zambian adults with sepsis and hypotension
  2. MERINO
  3. CASS trial
  4. C.Auris outbreak
  5. EUPHRATES

Trauma:

  1. PAMPer
  2. ENDAO
  3. Conservative management of traumatic pneumothoraces
  4. Outcomes following trauma laparotomy
  5. POLAR (Again)
  6. Incidental findings after whole body CT for trauma from REACT-2

Cardiac:

  1. NA versus A for cardiogenic shock after MI
  2. PARAMEDIC 2
  3. HEARTMATE 3
  4. TRICS
  5. CULPRIT-SHOCK

I’ll admit I am feeling a little raw after my evening drinks last night, and so feeling a little weaker than usual I opted for the frailty session. A good introduction as to what it means to get old and a new word for me during the first lecture (fecundity). Some good points made about the multiple dimensions of frailty, including the cognitive and social impact as well as the physical issues we so often concentrate on. This is always a good article to refer to I find.  There were 2 suggestions regarding measures that might impact on frailty and senescence; caloric restriction and exercise. The data presented was very interesting but challenging to envisage how we could use it in practice on critical care. A reference also to the potential dangers of excessive exercise, which was met by an audible gasp from a room full of cycling and running enthusiasts….. Lauren Ferrante was back on stage then talking about recognising what outcomes are most important to elder patients following critical illness. Some compelling data presented again to suggest that independence, rather than survival, is often the preferred metric for patients and that there are indeed states worse than death.  Frailty prior to ICU admission also appears to be significantly associated with increased disability after ICU discharge, increased mortality (up to 50% by three months) and increased likelihood of discharge to a nursing home. Worth bearing in mind, when attempting shared decision making with patients and families.  A further take home message at the end regarding frailty screening and it’s potential to frame patient centred decision making and highlight the burdens of survivorship.

Day 3: Brunch

Although I wanted to take a look at the brain this morning, I am always interested to hear what the voice of youth is saying. No better way to do this than through the Cauldron. And what could be more tempting than the allure of ‘critical care game changers’. I sat back comfortably and got ready to be persuaded to change my game. 

First up @chadwickRespICU tried to convince us that wrestling with our inherent biases could change the game. Gender bias as a specialty issue needs addressing. Our clinical bias and nihilistic decision making could be tempered. Personality bias impacting our wellbeing and consequently our recruitment needs an overhaul. Lots of very interesting stuff, but the dragons rightly brought up the issue of bias being inherent and the lack of proposed solutions. 

Our very own @hywelgarrard from Manchester after that espousing the death of the game changer. Why do we continually search for the next magic bullet or exciting tech when actually we have already changed the game, and continue to do so through cautious and methodical care? Boring is the new cool and the next big game changer is to stop looking for game changers, and simply to do the little things right. Kathy Rowan offered the challenge that we already do this and continue to drive it through GIRFT and other measures. Do we do it routinely though? I refer you to yesterdays blog and Brian Cuthbertson’s assertion that we are crap at delivering lung protective ventilation even in the context of clinical trial work…. 

@scottie_doc  then with his new paradigm for the ethics and legality of organ donation. Started by highlighting the >6000 on the transplant list as of March 2018, compared to the 1574 active donors of >7000 potential cases. Scot highlighted the 45% refusal rate by families and pushed us to change to an opt-out system such as that already established in Wales, with refusal of family vetoes. A utilitarian philosophy was pushed with a nod to the justice pillar of medical ethics – how can we place more moral emphasis on the grief and suffering of the family in front of us who are in conflict, than the grief and suffering of 8 other patients and families who are awaiting transplant? Interesting stuff, but intellectual copyright was rightly questioned… 

Matt Rowe then, riding the artificial intelligence juggernaught. Will these computational algorithms outperform human decision making and put us all out of a job? Matt honed in on predictive analytics and the opportunity that big data provides to process, cross reference and refine risk characteristics and scoring systems. There have been some good review articles on this stuff recently if you want to read more. Matt took this forward to highlight the possible advantages – cognitive offload, reducing staff fatigue, reduced costs and large research datasets enabling individualised patient management. There was a caveat about the need for humans, displaced to tasks requiring humans. More on this latter discussion here.  

Last but not least, Becky Lewis and her assertion that the next member of the MDT should be….wait for it……GERIATRICIANS. Interesting stuff. Parallels drawn with geriatric trauma in reach, emergency villages, surgical oversight and more. A compelling argument that embedded geriatricians could advise on admission, diagnostics, complications, discharge and follow up issues. Some real questions remain on this topic however -  in reach geriatricians already exist in most emergency villages; working patterns mean they would be unlikely to assist with the out of hours decision making, which is often the major issue for these patients. They could quickly become room meat in addition and perhaps their value is more in education and support than it is direct involvement in the MDT. 

This was a great session overall – some fantastic ideas, well presented and with good response to the questions. The ‘dragons’ of this session also flexed their muscles entertainingly throughout and all should be congratulated.  

Day 3: Afternoon

Awards, followed by an interesting reveal that the ICS research program is preparing a prioritisation exercise for 2019, where any ICS member can submit an idea to be developed by an expert Panel. I think this opportunity will go live in Spring next year, with an aim for the clinician body to vote on a winner at the next ICSSOA and win potential funding of up to £50,000. Great news. Ever thought you had a question in need of an answer – work it up locally with your research design service and get ready to submit…

Dale Needham then gave us a further walk through the PADIS guidelines, which were highlighted in the day 1 blog. Various summary recommendations: no role for pharmacological agents for prevention of delirium; no role for routine use of pharmacological agents to treat delirium; maybe a role for dexmedetomidine when agitation and delirium is precluding extubation. And lastly, my favourite, the guidelines support a role for multicomponent non-pharmacologic intervention in treatment and prevention of delirium.   

Dale number 2 then, with Dr Gardiner discussing the possibility of an opt-out program for organ donation in the UK. It seems we are building in this area, with a 95% increase in the amount of donors over the last decade. Consequently, the transplant waiting list has fallen for 8 consecutive years. Can we do more? Should we bring in opt out consent as discussed earlier in the Cauldron presentations? It appears that this concept has cross party political support and the plan is for England, Scotland and Ireland to all be primarily opt-out by 2021. In England, this would be through amendment to the Human Tissue Act 2004. The challenge now is to get the bill through parliament despite all the current tomfoolery. Fingers crossed, and watch this space. Naturally, this finished with a dancing pancreas. 

Last was a series of short trial summaries from the great minds behind the research. Jerry Nolan presented  AIRWAYS2 and Gavin Perkins talked about PARAMEDIC2. If you haven’t seen the summaries of these big studies already, have a look here and here. Kathy Rowan discussed the unpublished results of the POPPI trial, which was another well constructed and conducted piece of research from the ICNARC team. Have a look here for the primary outcome data . Geoff Bellingan then finished off here with a presentation on the negative results from the INTEREST trial looking at the role of interferon in lung injury, but with a caveat that research often breeds further questions. I am not sure he has quite closed the book on this yet, despite the seemingly identical pattern of those Kaplan-meier curves. Watch this space.  

Day 3: Other gems

Lots of other brilliance that I could not attend, so make sure you follow the social media team on twitter and the #ICSSOA2018 thread. More summary images have been posted on twitter again by Hugh Gifford and of course, the legendary @whistlingdixie4. Have a look at their timelines as well and digest at your leisure. 

All in all a great few days. Congratulations to Steve and the organising committee again. Suggestions welcome for future blogs and coverage of these events. We hope all this social media business allows the learning to continue outside the lecture theatre from these events and any ways you can think of to make that happen… let us know. 

See you next time. 

Dan @RCEMProf

Photographs by Simon Callaghanwww.simoncallaghanphotography.com