Dan Horner, Consultant in Emergency Medicine and Intensive Care at Salford Royal Hospital and St Emlyn's blogger, takes a look at day one of SOA 18.
St Emlyn’s is on tour (again) and this week I am at the Intensive Care Society State of the Art meeting in London. Always a truly international affair, with expert academic speakers from across the globe and the latest technology on display, next to homegrown talent and pragmatic clinical updates. Steve Mathieu has taken over curation this year and put together a fantastic and diverse program at a new and exciting location, so kudos to him and the organising team. There is even a magnificent squad of social media gurus helping me to navigate the concurrent sessions and squeezing all the educational juice from this particular orange – as such these blogs are a combined effort and early thanks go to Nitin, Jamie, Segun, Aoife, Jonathan, Rob, Rachael, Tanj and Philip, all of whom deserve a follow, a pat on the back and a promotion if you see them. Good work everyone.
Day 1: Morning
Plenary for us all to start with, and following a nice video and introduction we were right into the microbiome and critical illness with Hallie Prescott. A nice summary on what the microbiome actually is followed (a 1.5kg organ with more DNA than every other combined!), but if you want to dig deep and get to grips with it then this is the article. It seems we upset the microbial ecology of patients during critical illness. But how can we resuscitate the microbiome before, during, or more likely immediately after critical illness? Intranasal synbiotic therapy? Faecal implantation? Probiotics? This elegant study published in Nature suggests that the latter may be of benefit in reducing rates of neonatal sepsis, with a number needed to treat of 27. Interesting stuff.
Next up the Ashes; sepsis in Australia versus the UK. An interesting discussion about how you define sepsis and collect data, along with thresholds for admission and bed availability concluded that we are probably not too dissimilar. The talk then became a discussion of general treatment therapies - have a high index of suspicion, early response teams, talk to others and treat your staff well so the experts remain motivated. Simon Finfer finished by talking about education in the emergency department and recognition of sepsis as a time critical emergency; I suppose that goes on the pile alongside stroke, intracranial haemorrhage, STEMI, trauma, AKI, Cauda Equina Syndrome, the acute abdomen etc….
Brian Cuthbertson, eloquent as ever, talked about how we can improve critical care in the UK. After the preceding debate between protocols, pathways and autonomous decision making, Brian argued that the UK has too much of the latter. The case for the prosecution; OSCAR versus OSCILLATE and the baseline mortality increase of 6% in the UK control group compared to the Canadian trial, potentially influenced by our inability to follow protocols and deliver 6ml/kg tidal volumes even within the strict context of a randomised trial. This is a topical and interesting point and one currently under discussion on my unit. Do you prescribe your ventilation? How strict are you about delivery? Who is allowed to change your settings? Is there an audit trail of every adjustment? There was a nice Venn diagram where he suggested that EBM and patient preference should play larger roles than clinician experience and autonomy. This made me really think.
Brian followed this by talking bed availability. Another contrast between the UK and North America. A parallel to the Starling curve this time, and an argument that we can probably fill the system a bit more here and continue to improve our outcomes. Firstly by taking more patients, less unwell maybe, but with the potential to benefit from enhanced care, and second more of those who are very unwell, as our ability to prognosticate at the time of referral is poor. To effect this change he thinks we should be banging the political drum and evaluating change through robust cost effectiveness work. I enjoy these 2 aspects of the job as much as anyone….
The terrific Esther Murray was up next talking about Moral Injury. We had the pleasure of interviewing her several months ago and I would heartily recommend a listen, along with a read of her published work on this concept.
This session then finished with a tale straight out of a spy novel. James Haslam giving as detailed an account as allowed regarding recent first-hand experience of the Novichok poisoning in Salisbury. This was a great personal account from the people who directly managed the situation, outside their comfort zone and without prior warning. No wonder it got a standing ovation. James’ talk was also a good reminder of relevant toxidromes, point of care testing availability and antidote options. If you need a reminder on these have a look here.
Day 1: Lunch
After lunch was a quick fire updates session for me. First up – Dale Needham from Baltimore talking about delirium. The scene was set with a dialogue on the independent association with increased mortality and psychological morbidity. Then on to the usual stuff on avoidance measures and management; analgaesia first, light intermittent sedation when needed and multicomponent non-pharmacological approach when it occurs. Dale mentioned the PADIS guideline which as well as Pain Agitation and Delirium now also includes discussion of Immobilisation/rehabilitation and Sleep goals. Lots of further reading at ICUdelirium.org and deliriumnetwork.org .
Next, the acronymised duo of TTP and HUS presented by a dynamic duo. A case discussed, followed by a recap on diagnostic guidelines and evidence based management. Lots of good reminders here about TTP – the condition is prothrombotic, so don’t be scared of procedures even though the platelets may be low; ADAMTS13 level is the clincher for diagnosis; plasma exchange is the initial gold standard of treatment. Monoclonal antibody therapy/novel biologic agents also appear to be an option for refractory or acute relapsing disesase. Rituximab was suggested as an option, but I suspect this would need discussion with a specialist haematology service. There was also then some further talk of nanobodies and bortezomib (velcade). Sounds like fancy and expensive stuff to me – however the case demonstrated how these rescue options can sometimes result in a good outcome and multidisciplinary team working can save the day.
Then, the tricky extubation. Who is Tricky and how do we spot them? And if we suspect trickiness, how can we manage it? Lots of premorbid and acute admission risk factors were discussed along with our usual path of clinical assessment and spontaneous breathing trials. However, some excellent pointers followed on using ventilator diagnostics as an adjunct to determine the likelihood of successful extubation. The top three included:
Rapid Shallow Breathing Index
P0.1 (or P100, referring to 100ms)
Maximum Inspiratory Pressure
There was also mention of extubation onto NIV and High flow nasal cannulae, including when this might be appropriate. A nod to the Breathe trial here, successfully delivered by the UK Critical Care Research Forum recently which you should all read if you haven’t already.
Last up was Alex Psirides talking about dogs, horses and cows on the critical care unit. What’s not to like about that? Nothing, that’s what. Bring it on.
Day 1: Afternoon
On to the future of ICU for me. How do we address the challenges of an ageing population on the ICU? Lauren Ferrante wants us to understand the demographic and think hard about changes we can make NOW, that will make it easier for us to tackle this inevitable concern in the future. Suggestions included a clearer understanding of the impact of frailty, delineation of recovery goals (back to baseline at best) and setting realistic expectations for the patient and family members. In addition, Lauren presented data to show that patients with decline in ability prior to ICU admission are more likely to transition to a much worse functional status on discharge, or death. Particular characteristics such as sensory impairment may also help predict those less likely to make a good functional recovery. This information could be used to inform discussions regarding the suitability of critical care admission and to facilitate shared decision making. There was also talk of adopting a care model for elder patients on ICU. Interesting stuff.
Molecular diagnostics next. Began with a kicking for farmers and general practitioners, who were blamed (tongue in cheek) for rising prescriptions of broad spectrum antibiotics and increasing worldwide patterns of resistance. There was discussion of how we can influence this through stewardship on the ICU, but the inevitable question followed of whether molecular diagnostics can help. Will results from the SEPTIFAST, TEST IT and VAP-RAPID studies tell us more? Interesting final message that if this technology is going to make a difference, then we will need to believe the results – negative will need to mean negative, and de-escalation, which will mean a culture change for those of us who think the patient ‘still looks a bit peaky and just needs a few more days’. Watch this space.
Last up was Haille Prescott again talking about managing increasing public expectations, with particular reference to the New York State initiative for sepsis. Some strategies include trying to harness the engagement for good; they have found that family presence during ward rounds can lead to more accurate clinical information about the patient, vigilance for professionalism, fewer afternoon updates and potentially more engagement in both clinical decision making and research activity.
Day 1: Other gems
Some wonderful summary images have been constructed on all todays talks by Hugh Gifford and of course, the legendary @whistlingdixie4. Have a look at their timelines and digest at your leisure.
Looking forward to more tomorrow. Until then, I am off to do some networking at the markets with additional mulled something and Strudel. I suggest you all do the same.
Dan Horner is a dual Emergency Physician and Intensive Care consultant working in a major trauma and neurosciences centre in Manchester. He is also Professor of the Royal College of Emergency Medicine. When he gets time, he blogs at www.stemlynsblog.org and tweets at @RCEMProf.