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Qatar Medical Journal - 2 - Qatar Critical Care Conference Proceedings, February 2020
2 - Qatar Critical Care Conference Proceedings, February 2020
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The inaugural Qatar Critical Care Conference with its Qatar Medical Journal Special Issue – An important milestone
Authors: Ibrahim Fawzy Hassan and Guillaume AlinierEditorialDr. Ibrahim Fawzy Hassan
Local Host and QCCC 2019 Conference Chair
Dear Friends and Colleagues,
It is an honour to welcome everyone to the first Qatar Critical Care Conference (QCCC). It has been a long journey to make it happen, but this event has been much awaited by the local critical care community. Over the last few years, we have hosted a number of related events of various scales, ranging from Critical Care Grand Rounds targeting Hamad Medical Corporation (HMC) critical care clinicians, ran specialised courses, through to organising an international medical conference on extracorporeal life support in 2017.1 This inaugural QCCC event is the fruit of much planning and collaboration. The programme spans from 28th to 31st October 2019 and consists of two days of pre-conference workshops and two days for the main conference.
The vast majority of the pre-conference workshops will be held in the state-of-the-art ITQAN Clinical Simulation and Innovation Centre located within Hamad bin Khalifa Medical City. Although the facility is yet to be offically inaugurated and opened, we have the privilege to have been granted access to it as a way of showcasing our forthcoming continuing professional development capability. “Itqan” in Arabic means quality and striving for perfection, which is very much in line with the mission of our established Critical Care Network (CCNW).2 Simulation-based education is an area in which we have started to be very active through various immersive courses as well as innovative technological developments to train our extracorporeal membrane oxygenation (ECMO) specialists.3,4
The scientific part of the conference will be hosted in the iconic Sheraton Grand Doha Resort & Convention Hotel in the West Bay area. It includes a varied selection of topics presented by many renowned experts in their respective domain. This comprehensive programme with a line-up of lectures and workshops addressing e-CPR, ECMO simulation, ECMO cannulation, hemodynamics and so much more will facilitate the exchange of knowledge and experiences to improve patient care in Qatar and beyond. We anticipate that the programme will appeal to a broad audience and hence will bring together clinicians from all professions involved with caring for acutely ill patients. It is QCCC's aim to connect and explore new insights and expertise at a national and international level through networking with other professionals in a multidisciplinary setting. We hope that during this event many fruitful discussions will take place and that it will enhance opportunities for collaboration to develop everyone's practice in critical care.
The HMC Critical Care family has a capacity of 163 and 109 intensive care unit (UCI) beds, respectively for adult and paediatric patients, across 7 hospitals spread throughout Qatar. These numbers are complemented by another 52 adult and paediatric beds from non-HMC hospitals. This gives us a national ICU bed capacity of 11.8 per 100,000 inhabitants considering a current population of nearly 2,750,000 inhabitants.5 Although this number remains below the international benchmark which can be considered to be around 15/100,000 population,6 this quota in Qatar has more than quadrupled over the last ten years, which represents a very significant improvement in the care that can be provided to acutely ill patients. Within HMC only, it is supported by a workforce of 159 intensive care physicians, 1122 intensive care nurses, and many other clinical staff, all of whom undergo a well regulated programme of continuing professional development and are licensed to practise by the Qatar Council for Healthcare Practitioners (QCHP).7 The work they do across the various sites is coordinated and monitored by the CCNW2 who ensures the best level of care, up-to-date technology, and evidence-based practices are consistently adopted for the wellbeing of our patients.
Once again, on behalf of the Scientific and Organizing Committees, it is my pleasure to welcome you all to Doha and we hope that you enjoy and gain meaningful insights during the conference regarding our local critical care setting and practices, but also learn from the experiences and best practices shared by our international guest speakers.
Prof. Guillaume Alinier
Guest Managing Editor, Qatar Medical Journal QCCC Special Issue and Abstracts Chair of the QCCC Scientific Committee.
Dear Contributors and Conferences Delegates,
Welcome to this special issue of the Qatar Medical Journal (QMJ) which has been dedicated to the inaugural conference of the Hamad Medical Corporation (HMC) Qatar Critical Care Network (QCCN) which celebrates its fifth anniversary in 2019. I would like to start by thanking everyone who has supported this arduous publication endeavour through their extended abstract submission(s) and the reviewers for the valuable feedback they have provided to the authors to ensure this publication is a representative legacy of the calibre of this conference which includes many local and international experts in their respective field of practice or interest. All the accepted abstracts are being published Open Access thanks to the support of the conference sponsors and this contributes greatly to the sharing of experiences and best practices worldwide, but also showcases the good work that is being done in Qatar in the domain of critical care thanks to the work of dedicated clinicians and the leadership of the CCNW.2
Being the Guest Managing Editor of the special issue of a journal is an honour but also an arduous task, especially when a large number of submissions from international authors needs to be handled. It is the second time that I have accepted to take on that role for Qatar Medical Journal as the previous time was in 2017 on the occasion of hosting the South West Asia and African Chapter (SWAAC) of the Extracorporeal Life Support Organisation (ELSO) in Doha.1 This was only a couple of years after HMC had established its Extracorporeal Membrane Oxygenation (ECMO) programme, and it was a very successful event with many of its associated open access publications having been downloaded hundreds of times from the QScience.com publishing platform.
Working on this new Special Issue really made me reflect on how the domain of critical care is vast and encompasses so many aspects of patient care and so many professions and specialties. The topics of the abstracts published in this special issue of QMJ cover dietetics,8 sepsis,9 delirium,10,11 physical therapy,12 end of life care and organ donation,13,14 dealing with families,15 as well as education and training of clinicians,16,17 to only highlight a few. Critical care is fast moving as new clinical practices and technological innovations are adopted and contribute to continuously improving patient care. This is especially true in Qatar where significant investments are constantly made to develop and support healthcare in a strategic way.18 At HMC, the critical care phase that some patients have to go through so their medical needs can be met is well integrated across all stakeholder departments that can possibly be involved.2 The patient's journey through the healthcare system can be seen as a continuum of care facilitated by the fact that all parties involved belong to the same overarching organisation, HMC, which is the government funded main provider of secondary and tertiary healthcare in Qatar. This means that from initial contact with the Ambulance Service bringing a patient to the Emergency Department for example, right through to rehabilitation and even possible access upon discharge to a mobile healthcare service supported by family physicians, nurses, and paramedics, patients can expect the same high standards of care.19 Critical care provision relies on multidisciplinary communication during transition of care as well as during any acute episode. This needs to be underpinned by medical knowledge and understanding of the potential contributions of other professions as nothing can be left to chance when a patient's life is hanging by a thread. The present collection of editorials and abstracts brings different perspectives on a broad range of topics which should be highly relevant to all clinicians involved with critical care and contribute to improving patient outcome and satisfaction, and hence that of the multidisciplinary team members also involved in caring for them.
We hope that the Qatar Medical Journal Special Issue publications on critical care meets your needs and expectations. The complete record of QCCC publications including additional open access abstracts and editorials relating to this conference will be made available in Qatar Medical Journal at the following link: https://www.qscience.com/content/journals/qmj. Thanks again to everyone for your contributions, and beyond our email communications, I now hope to meet you in person during the conference!
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Critical Care Network in the State of Qatar
EditorialCritical care is a multidisciplinary and interprofessional specialty providing comprehensive care to patients in an acute life-threatening, but treatable condition.1 The aim is to prevent further physiological deterioration while the failing organ is treated. Patients admitted to a critical care unit normally need constant attention from specialist nursing and therapy staff at an appropriate ratio, continuous, uninterrupted physiological monitoring supervised by staff that are able to interpret and immediately act on the information, continuous clinical direction and care from a specialist consultant-led medical team trained and able to provide appropriate cover for each critical care unit, and artificial organ support and advanced therapies which are only safe to administer in the above environment. It is an important aspect of medical care within a hospital as it is an underpinning service without which a hospital would not be able to conduct most or all of its planned and unplanned activities. As such, critical care requires a very intensive input of human, physical, and financial resources.2 It occupies a proportionately large fraction of a hospital's estate and infrastructure for a small number of patients. The resources that are invested into a critical care bed should therefore be valued against the activities and care throughout the hospital that the availability of that bed allows to happen. Given that demand for critical care beds will continue to grow, providing more critical care beds is unlikely to work on its own since experience has shown that additional capacity is soon absorbed within routine provision.3 Attention must therefore be given to maximising the efficient and effective use of existing critical care beds, necessitating an ability to cope with peaks in demand.
Historically the world over, the development of critical care units has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development. However, there is now an eminent body of opinion that supports an alternative approach to critical care provision – namely through a managed Critical Care Network with an agenda of integrated working and the focus on facilitating safe quality care that is cost-effective and patient-focused for acutely and critically ill patients across the various constituent organisations of a healthcare system.
The Critical Care Service in Hamad Medical Corporation (HMC) has developed rapidly to address the increasing demand linked to the population growth in the State of Qatar with the aim of meeting the vision of the National Health Strategy (NHS). It is paralleled with HMC's vision to improve the delivery of critical care to patients and their families in a way that meets the highest international standards such as those set by the Joint Commission International by whom the Corporation has been accredited since 2007.4 For this reason, the organisation took the lead to perform a gap analysis with expert auditors from the United States of America and the United Kingdom who have experience in critical care service provision. The aim was to assess the Critical Care Service within HMC and identify potential short-term, medium-term, and long-term opportunities for improvement. This assessment focused on a very broad range of aspects such as: bed capacity, facilities and equipment, medical, nursing and allied healthcare staffing levels and their education, career development pathways, patient safety, quality metrics, clinical governance structure, clinical protocols and pathways, critical care outreach, and future planning for critical care at HMC.
As a result of extensive review for the Critical Care Services at HMC, the Critical Care Network (CCNW) in the State of Qatar was established in 2014. It is a strategic and operational delivery network, which includes 12 hospitals across the country. The network functions through a combination of strategic programmes, working groups, and large multidisciplinary governance and professional development events. Through collaborative working with the leadership of the various facilities and critical care clinicians, the network reviews services and makes improvements where they are required, ensuring delivery of patient-focused care by appropriately educated and trained healthcare professionals as well as the appropriate utilisation of critical care beds for those patients who require such care. Detailed involvement and engagement from the clinical membership at every event and in the various working groups ensures that all decisions, reports, and improvement programmes are clinically-focused and benefit from a diversity of opinions that can be considered for implementation. All of this is carefully aligned to the requirements of the latest Qatar National Health Strategy.5
It aims to adopt evidence-based best practices to deliver the safest, most effective and most compassionate care to our critical care patients by setting the most appropriate care pathway to transform Critical Care Services across HMC hospitals. The key aims of the CCNW as stated in its Terms of Reference document are listed in Table 1.6 This enhances the quality and safety of patient care across HMC, promotes staff satisfaction, and improves customer service and patient outcome. The CCNW is structured in a way that involves all Critical Care Service stakeholders to maintain the stability and sustainability of delivering the best care to critically ill patients.
The CCNW is steered by a multidisciplinary committee (Figure 1) that is empowered with the generative, managerial, and fiscal responsibilities to enable the required changes to take place. The committee oversees the HMC Critical Care Services through coordinating and standardising their activities and governance arrangements across the complete HMC healthcare system. It provides HMC clinical and managerial leadership at a corporate and local level, the opportunity to jointly develop critical care standards, policies, and operating procedures. In doing so, the CCNW decides on and implements recommendations on how to best plan and deliver critical care services using evidence-based practice set against the context of national and international practices. The HMC CCNW gives recommendations to various committees to improve the services in the following areas:
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1. Defining the level of care and critical care core standards for HMC: The CCNW standardises critical care across the Corporation regardless of where it is being delivered. As such it develops the critical care core standards for the critical care units and gives recommendations regarding future critical care core facility planning within HMC. The CCNW helps the Ministry of Public Health (MoPH) develop the National Critical Care Core Standards.
2. Quality and safety: The CCNW works collaboratively with HMC leaders to ensure a culture of quality is embedded within all critical care services delivered within HMC. There is a continuous evaluation process in place to measure the quality of care for high performance critical care which is the goal. This is based upon ongoing observations, robust data collection and analysis, and a change management strategy implemented as required.
3. Clinical pathways, guidelines, and protocols: The CCNW develops, according to international best practice, clinical care pathways, guidelines, and protocols that govern critical care units throughout HMC. Critical care clinical practice is audited against these standards, compared with the international benchmark, and updated as required to ensure currency of all patient care aspects.
4. Transfer and transportation of critically ill patients: The CCNW develops HMC-wide criteria for patient intramural, extramural, and international transfers, and sets standards of care during transportation in collaboration with the HMC Ambulance Service Transfer and Retrieval team. This includes HMC-wide bed management consideration with the senior consultants on call, review of the patient's condition and medical needs, and assessment of the mission associated risks and mitigating strategies. This involves significant planning on the part of the team, clear communication and handovers, and the use of checklists at several stages to ensure the provision of safe and efficient patient transfers.
5. Education: The CCNW develops educational plans and ensures corresponding courses accredited by the Qatar Council for Healthcare Practitioners (QCHP) are designed and delivered to address the training needs of clinicians. The portfolio of courses is regularly reviewed to meet identified needs so clinicians always possess the appropriate knowledge and skills to manage critically ill patients.
6. Research and Critical Care Data Registry development: Being a key player in an Academic Health System, HMC fosters a relatively young but growing research environment4 of which the CCNW forms an integral part. Creating opportunities for epidemiological research and also fulfilling the needs for quality monitoring and benchmarking, the CCNW has enabled the creation of critical care data registries. Such registries provide a valuable source of information and have already been exploited at HMC to better understand the type of patients a service cares for and patient outcomes with respects various factors.7
The establishment of a CCNW at a corporate level (with membership from local leaders across HMC) has provided a level of oversight and leadership which has significantly contributed to optimizing and reshaping the way acutely ill patients are cared for. It has enabled the adoption of evidence-based best practices across the various critical care services of HMC as well as created a multidisciplinary forum for dialogue and collaboration. Innovative work focusing on providing effective, up-to-date, and patient-focused care are ongoing as well as HMC's pursuit of various international accreditation awards by prestigious organisations and professional bodies.
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Surgical intensive care – current and future challenges?
Authors: Stefan Alfred Hubertus Rohrig, Marcus D. Lance and M. Faisal MalmstromEditorialBjorn Ibsen, an anesthetist who pioneered positive pressure ventilation as a treatment option during the Copenhagen polio epidemic of 1952, set up the first Intensive Care Unit (ICU) in Europe in 1953. He managed polio patients on positive pressure ventilation together with physicians and physiologists in a dedicated ward, where one nurse was assigned to each patient. In that sense Ibsen is more or less the father of intensive care medicine as a specialty and also an advocate of the one-to-one nursing ratio for critically ill patients.
Nowadays, the Surgical Intensive Care Unit (SICU) offers critical care treatment to unstable, severely, or potentially severely ill patients in the perioperative setting, who have life-threatening conditions and require comprehensive care, constant monitoring, and possible emergency interventions. Hence there is one very specific challenge in the surgical setting: the intensivist has to manage the patient flow starting from admission to the hospital through to the operating theater, in the SICU, and postoperatively for the discharge to the ward. In other words, the planning of the resources (most frequently availability of beds) has to be optimized to prevent cancellations of elective surgical procedures but also to facilitate other emergency admissions. SICU intensivists take the role of arbitrators between surgical demand and patient's interests. This means they supervise the safety, efficacy, and workability of the process with respect to all stakeholders. This notion was reported in 2007 when Stawicki and co-workers performed a small prospective study concluding that it appears safe if the dedicated intensivist takes over the role of the last arbitrator supported by a multidisciplinary team.1
However, demographic changes in many countries during the last few decades have given rise to populations which are more elderly and sicker than before. This impacts on the healthcare system in general but on the intensivist and the ICU team too. In addition, in a society with an increased life expectancy, the balance between treatable disease, outcome, and utilization of resources must be maintained. This fact gains even more importance as patients and their families claim “high end” treatment.
Such a demand is reflected looking at the developments that have taken place over the last 25 years. Mainly, the focus of intensive care medicine was on technical support or even replacement of failing organ systems such as the lungs, the heart, or the kidneys by veno-venous extracorporeal membrane oxygenation (VV-ECMO), veno-arterial ECMO (VA-ECMO), and continuous veno-venous hemofiltration (CVVH) respectively. This means “technical care” became a core capability and expectation of critical care medicine. In parallel, medical treatment became more standardized. For example, lung protective ventilation strategies, early enteral feeding, and daily sedation vacation are part of modern protocols. As a consequence, ventilator time has been reduced and patients therefore develop delirium less frequently. These measures, beside others, are implemented in care bundles to improve the quality of care of patients by the whole ICU team.
The importance of specialty trained teams was already pointed out 35 years ago when Li et al.,2 demonstrated in a study performed in a community hospital that the mortality was decreased if an ICU was managed 24/7 by an on-site physician. The association of improved outcomes and presence of a critical care trained physician (intensivist) has been shown in several studies since that time.3,, 4,, 5,, 6 A modern multidisciplinary critical care team consists at least of an intensivist, ICU nurse, pharmacist, respiratory therapist, physiotherapist, and the primary team physician. Based on clinical needs, the team can be supplemented by oncologists, cardiologists, or other specialties. Again, this approach is supported by research: a recent retrospective cohort study from the California Hospital Assessment and Reporting Taskforce (CHART) on 60,330 patients confirmed the association between improved patient outcome and such a multidisciplinary team.7
If such an intensive care team makes a difference, why do not all patients at risk receive advanced ICU-care? It was already demonstrated by Esteban et al., in a prospective study that patients with severe sepsis had a mortality rate of 26% when not admitted to an ICU in comparison to 11% when they were admitted to an ICU.8 Meanwhile, we know that early referral is particularly important, because for ischemic diseases the timing appears to make a difference in terms of full recovery.
So, the following questions arise: Should intensive care be rolled out to each ward and physical admission to an ICU or be restricted to special cases only? For this purpose, the so-called “Rapid Response Teams” (RRT) or “Medical Emergency Team” (MET), which essentially are a form of an ICU outreach team, were implemented. The name, composition, or exact role of such team varies from institution to institution and country to country. Alternatively, should all ward staff be educated to recognize sick patients earlier for a timely transfer to a dedicated area? This would mean that ICU-care would be introduced in the ward.
A first attempt to answer this question, whether to deploy critical care resources to deteriorating patients outside the ICU 24/7, was given by Churpek et al.9 The success of the rapid response teams could be related to decreased rates of cardiac arrest outside the ICU setting and in-hospital mortality. Interestingly, an analysis of the registry database of the RRT calls in this study showed that the lowest frequency of calls occurred between 1:00 AM to 6:59 AM time period. In contrast, the mortality was highest around 7 AM and lowest during noon hour. This indicates that not simply the availability of such a team makes a difference but also the alertness of the ward-teams is of high importance to identify deteriorating patients in a timely manner. Essentially, this would necessitate ward staff being trained to provide a higher level of care enabling them to better recognize when patients become sicker to avoid a delayed call to the ICU.
Alternatively, a system in which the intensivist plays a major role in daily ward rounds could be beneficial. So, the ward doctor should become an intensivist. However, the latter means the ICU is rolled out across the whole hospital which would consume a huge amount of resources.
Another option would be 24/7 remote monitoring of patients at risk that notifies the intensivist or RRT in case of need. The infrastructure, technology, and manpower to put this in place also has associated costs.
As the demand for ICU care will rise further in the future, intensivists will play an even more important role in the healthcare system that itself is under enormous economic pressure to ensure the best quality of care for critically ill patients. Besides excellent knowledge and hard skills, intensivists need to be team players, communicators, facilitators, and arbitrators to achieve the best results in collaboration with all involved in patient treatment.
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Sepsis Care Pathway 2019
By Ahmed LabibEditorialBackground: Sepsis, a medical emergency and life-threatening disorder, results from abnormal host response to infection that leads to acute organ dysfunction1. Sepsis is a major killer across all ages and countries and remains the most common cause of admission and death in the Intensive Care Unit (ICU)2. The true incidence remains elusive and estimates of the global burden of sepsis remain a wild guess. One study suggested over 19 million cases and 5 million sepsis-related deaths annually3. Addressing the challenge, the World Health Assembly of the World Health Organisation (WHO) passed a resolution on better prevention, diagnosis, and management of sepsis4. Current state of sepsis guidelines: Despite thousands of articles and hundreds of trials, sepsis remains a major killer. The cornerstones of sepsis care remain early recognition, adoption of a systematic evidence-based bundle of care, and timely escalation to higher level of care. The bundle approach has been advocated since 2004 but underwent major modifications in subsequent years with more emphasis on the time-critical nature of sepsis and need to restore physiological variables within one hour of recognition. A shift from a three and six-hour bundle to one-hour bundle has been recommended5. This single hour approach has been faced with an outcry and been challenged6–8. One size never fits all: Over several decades, the individual components of the sepsis bundle have not changed. Encountering a patient with suspected sepsis, one should measure lactate, obtain blood cultures, swiftly administer broad spectrum antimicrobials and fluids, and infuse vasopressors. A critical question arises: should we do this for all patients? Sepsis is not septic shock and guidelines did not make distinctive recommendations for each. Septic patients will present differently with some having more subtle signs and symptoms. Phenotypically, we do not know which patient with infection will develop a dysregulated host response and will succumb to sepsis and/or shock6–8. The existing bundle lacks high quality evidence to support its recommendations and a blanket implementation for all patients with ‘suspected’ sepsis could be harmful7. Indeed, a significant reduction of sepsis and septic shock in Australia and New Zealand was observed in a bundle-free region8. Emergency Department (ED) challenges: Upon arrival in the ED, patients will be triaged. This is ‘time zero’5. Those with hypotension and hypoperfusion will be easily recognised and at most need to receive emergent care. Sepsis, per se, may not manifest clear cut signs and expertise to identify it is required. Those with non-specific symptoms may trigger an early warning scoring system and receive unnecessary antimicrobials and a large volume of intravenous (IV) fluids. Both therapies are not without significant side effects. Putting pressure on ED physicians to implement the 60-minute bundle without individualisation of care puts our patients at risk6–8. Diagnostic challenges: Given the heterogenous nature and diverse pathobiological pathways, sepsis diagnosis can be challenging and both over and under-treatment can result. Established biomarkers such as procalcitonin and C-reactive protein lack specificity to rule out infection as the cause of inflammation. Currently, no laboratory test or biomarker helps predict which patients with infection or inflammation will develop organ dysfunction. A dire need for a specific sepsis biomarker exists10.
Modern molecular-based technologies are evolving and utilise polymerase chain reaction (PCR), nanotechnology, and microfluidics for point-of-care testing. Some devices identify causative microorganisms and their sensitivity in less than an hour10. The bundle components: Catecholamines along with IV fluids are indicated to restore perfusion. However, inadvertent side effects may arise, especially at higher doses. Anti-adrenergic ß-blockers improve cardiac performance, enhance receptor responsiveness, and possess anti-inflammatory action. All are desirable in patients with septic shock11.
One randomised trial showed beneficial and protective effects of ß-blockers in septic shock. Rapidly acting titratable agents should be used in conjunction with appropriate hemodynamic monitoring and after adequate volume resuscitation. There is no consensus on target heart rate but an arbitrary cut off of 80–95 beats per minute is reasonable11.
Fluid resuscitation is the cornerstone of sepsis management. There is also compelling evidence that too much fluid is bad. Starch-based colloids should not be used in septic shock. Albumin is an alternative when large volumes are required but is not appropriate in traumatic brain injury. Balanced, less chloride and less acidic crystalloids are safer for the kidneys and are preferred over normal saline. Doses of IV fluids should be tailored to the patient's condition and a 30 ml/kg recommendation should be reviewed.12
Effective sepsis management requires adequate dosing of antimicrobials. Significant alteration of pharmacokinetics and pharmacodynamics is characteristic of septic shock13. Accurate and effective dosing is challenging particularly in patients with multiple comorbidities and those receiving extracorporeal organ support. Underdosing results in treatment failure, whilst overdosing leads to toxicity and the risk of developing multi-drug resistant organisms13. An individualised approach supported by therapeutic drug monitoring is suggested to ensure clinical efficacy13. Sepsis research: The search for a cure for sepsis is ongoing. A large prospective, randomised two-arm, parallel group study aims to recruit over 200 patients with septic shock across critical care units in Qatar. Evaluation of Hydrocortisone, Vitamin C, and Thiamine (HYVITS) examines the safety and efficacy of this triple therapy14. Sepsis in the young patient: Children are particularly vulnerable to sepsis. 1 in 6 children admitted with septic shock to ICU will die. As the majority of paediatric sepsis cases are community acquired, there is a strong need to raise awareness both for families and primary healthcare providers. Akin to adults, a bundle-approach to paediatric sepsis is strongly encouraged. National programs for paediatric sepsis have been established15. The Qatar paediatric multidisciplinary sepsis program was established under the umbrella of the adult programme in 2017. A structured and standardised approach to sepsis across all neonate and paediatric facilities has been developed and implemented. Improvement in timely sepsis recognition and administration of antimicrobials within the golden hour has been observed. The program aims to achieve a 95% compliance to the paediatric sepsis bundle by the end of 2019. A screening tool and order set have been put in place and are presented in this special issue of Qatar Medical Journal16,17. Obstetric sepsis: Pregnancy and childbirth are risk factors for sepsis. Multi-organ failure and death can result from puerperal sepsis18. Sepsis is the direct and leading cause of maternal mortality in the UK19. Attention to maternal sepsis with a tailored approach is encouraged. The Qatar National Sepsis Program developed a sepsis care pathway for pregnant women and during their early post-partum period. Challenges in low socioeconomic societies: A broader, national –or better yet– a global approach to further sepsis management and outcome should be considered. There are a number of significant challenges to address. One such challenge is the inconsistency of the operational definition and diagnostic approaches for sepsis including coding and documentation1,3.
Significant deficiencies in healthcare systems have been highlighted by sepsis. This is most obvious in medium- and low-income countries. A major limitation to effective sepsis management is inadequate medical staffing and poor knowledge and awareness of sepsis. Both have a negative impact on sepsis outcome3.
Poor medical facilities in many countries pose significant challenges to sepsis care. Lack of critical care capacity – a global phenomenon – has been linked to poor outcome of sepsis cases and septic shock. This could be attributed to provision of suboptimal critical care, monitoring and critical interventions outside of the ICU. ICU availability is subject to inconsistency and inequity.2,3
Lack of adequate surgical capacity to accomplish timely source control adversely affects sepsis management. This, unfortunately, in medium- and low-income countries, is accompanied by inadequate medical supplies, diagnostic capacity, and manpower which increases sepsis mortality and morbidity3. Global concerns: Antimicrobials are critical for sepsis care. A global concern is the development of multi-drug resistant organisms and the lack of novel antimicrobials and this adds pressure on those caring for septic patients. Effective antimicrobials should be utilised to eradicate infections. Misuse, inadequacy, inferior agents, and lack of timely access to effective and affordable agents significantly hinders patient's recovery from sepsis2,3.
Optimum sepsis outcome mandates attention to acute sepsis complications (e.g. acute renal or respiratory failure) as well as addressing post-discharge complications and disability. These challenging issues remain poorly studied or addressed3. Conclusion: Sepsis and septic shock are major global health concerns. Progress has been achieved in understanding this life-threatening syndrome at a biological, metabolic, and cellular level. Efforts should be coordinated to improve sepsis care. Better and more accurate diagnostics are needed and governments are encouraged to invest in sepsis research and care. More integrated, inclusive, and focused research is desperately needed. Public education and increased awareness among primary healthcare providers are also critical to improve sepsis outcome.
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Trauma intensive care unit (TICU) at Hamad General Hospital
EditorialTrauma is a leading cause of mortality and morbidity worldwide, and thus represents a great global health challenge. The World Health Organization (WHO) estimated that 9% of deaths in the world are the result of trauma.1 In addition, approximately 100 million people are temporarily or permanently disabled every year.2 The situation is no different in Qatar, and injury related morbidity and mortality is increasing in the entire region, with road traffic collisions (RTCs) being the most common mechanism.1
It is well recognized now that trauma care provided in high-volume, dedicated, level-one trauma centers, improves outcome. Studies have also looked at what are the components of a trauma system that contribute to their effectiveness2. However, in general, it usually implies a high-volume of cases, dedicated full-time trauma qualified professionals, a solid pre-hospital system, a multidisciplinary team, and excellent rehabilitation services.
Similarly, critically injured trauma patients managed in a dedicated trauma intensive care unit (TICU), has been shown to improve outcomes, especially for polytrauma patients with traumatic brain injury (TBI).3 In fact, the American College of Surgeons (ACS) Committee on Trauma requires verified trauma centers to have a designated ICU, and that a trauma surgeon be its director.4 Furthermore, studies have shown that for TBI, it is not necessary for this ICU to be a neurocritical care unit, but rather it should be a unit that is dedicated to trauma, that has standardized protocols for TBI management.5,6 In fact, the outcomes are better in the latter, with lower mortality in multiple-injured patients with TBI, when admitted to a TICU (versus a medical-surgical ICU or neurocritical care unit).3 These benefits were shown to increase, with increased injury severity. The proposed reason for this is thought to be due to the associated injuries being managed better.7
The aim of this editorial is to describe the TICU at Hamad General Hospital (HGH), at Hamad Medical Corporation (HMC), including a comparison of its data and outcomes with other similar trauma centers in the world. The Qatar Trauma Registry, as well as previous publications from our Trauma Center,1,8 were used to obtain HGH TICU and worldwide Level-1 Trauma Center standards, respectively.
With respect to HGH, the TICU is part of an integrated trauma program, the only level-1 trauma centre in Qatar. It provides the highest standard of care for critically-ill trauma patients admitted at HGH, striving to achieve the best outcomes, excellence in evidence-based patient care, up to date technology, and a high level of academics in research and teaching. This integrated program includes an excellent pre-hospital unit, emergency and trauma resuscitation unit, TICU, trauma step-down unit (TSDU), inpatient ward, and rehabilitation unit.
The new TICU is a closed 19-bed unit, that was inaugurated in 2016, is managed 24/7 by highly qualified and experienced intensivists (9 senior consultants and consultants), along with 24 well-trained and experienced associate consultants or specialists, and fellows and residents in training, as well as expert nursing staff (1:1 nurse to patient ratio) and allied health professionals (respiratory therapists, pharmacists, dieticians, physiotherapists, occupational therapists, social workers, case managers, and psychologists). It is supported by all medical and surgical subspecialty services.
It is equipped with the latest state-of-the-art technology and equipment, including ‘intelligent ventilators”, neuro-monitoring devices, ultrasound, point-of-care testing such as arterial blood gas and rotational thromboelastrometry (ROTEM), and video airway devices.
The TICU is a teaching unit, linked to the HMC Medical Education department, with presence of fellows, and residents (see below for details). Medical students (Clerkship level) from Weill-Cornell Medicine Qatar also complete a one-week rotation in the TICU, as part of their exposure to critical care. The first batch of clerks from Qatar University College of Medicine are expected to start rotating in the TICU soon.
The Trauma Critical Care Fellowship Program (TCCFP) is an ACGME (Accreditation Council for Graduate Medical Education) fellowship that was established over seven years ago. To date, over 40 physicians from both within, and out of, the trauma department have completed the program. Up to seven fellows, including international candidates, are trained each year. A number of physicians have succeeded in gaining the European Diploma of Intensive Care Medicine (EDIC). The program continues to attract many applicants from various specialties including surgery, anesthesia, and emergency medicine. An increasing number of international physicians from Europe and South America have expressed interest in applying for our fellowship. The first international fellows are likely to join us from early 2020.
Residents (from general surgery, ER, ENT, plastics, orthopedics, and neurosurgery) rotate (one to three months’ rotations) in the TICU, and are actively part of the clinical team.
There were 568 admissions to the TICU in 2018. The patients admitted were either mainly polytrauma patients with varying degrees and combinations of head, chest, abdominal, pelvic, spine, and orthopedic injuries, or isolated-TBI. Of these patients, 378 were severely injured with an injury severity score (ISS)9 greater than 16.
According to previously published data from our Trauma Centre,1,8 our mortality rates (overall approximately 6-7%, as well as when looked at in terms of early and late deaths) compare favorably with other trauma centers around the world, when looking at similarly sized retrospective studies.
The TICU continues to be an active member of the Critical Care Network of HMC.10 This network involves all of the ICU's in all the HMC facilities. The main processes that the TICU is presently involved in as part of this network are: patient flow, clinical practice guidelines, evaluation and procurement of technologies, HMC sepsis program, and in general, taking part in any process that pertains to critical care at HMC.
A number of quality improvement projects are being undertaken in the TICU. Examples of such projects include:
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- Decreasing rates of infection in TICU
- Score-guided sedation orders to decrease sedation use, ventilator days and length of stay
- Reducing blood taking and associated costs
- Sepsis alert response and bundle compliance
- Medical and surgical management of rib fractures
Similarly, many research projects are taking place in the TICU, in coordination with the Trauma Research program, and often in collaboration with other departments (local and international). Examples of some of the research projects include:
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- The “POLAR” study (RCT on Hypothermia in TBI)11
- B-blockers in TBI (RCT-ongoing)
- Tranexamic acid (TXA) for bleeding in trauma (RCT-ongoing)
The team is also involved in conducting systematic reviews in relation to the role of transcranial doppler in TBI,12 sepsis in TBI patients (ongoing), self-extubation in TBI patients,13 safety and efficacy of phenytoin in TBI (ongoing), and optic nerve diameter for predicting outcome in TBI (submitted).
The TICU at HGH is a high-volume, high acuity unit that manages all the severely injured trauma patients in Qatar. It is well staffed with highly trained and qualified personnel, and utilizes the latest in technology and state-of-the-art equipment.
It performs very well, when compared to other similar units in the world, and achieves a comparable, or even lower mortality rate.
With continued great support from the hospital, corporation administration, and Ministry of Public Health, the future goals of the TICU will be to maintain and improve upon the high standards of clinical care it provides, as well as perform a high quality and quantity of research, quality improvement initiatives, and educational work, in order for it to be amongst the best trauma critical care units in the world.
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Taking upstairs care outside
By Ian HowardEditorialBackground: Critical care is a clinically complex and resource intensive discipline, the world over. Consequently, the delivery of these services has been compounded by the need to sustain a specialized workforce, while maintaining consistent and high standards.1,2 The regionalization of critical care resources and the creation of referral networks has been one approach that has led to success in this area.2–7 However, as steps have been made towards regionalization, so too has the need to transfer patients between facilities in order to access these services. The effects of this are already apparent, where estimates in the United States have found that 1 in 20 patients requiring intensive and critical care resulted in transfer to another facility.2 The need for such transfers are equally varied as they are common and include: no critical care facilities at the referring facility; no staffed critical care bed availability at referring facility; requirements for expertise and/or specialists facilitates not available at referring site; and the repatriation of patients back to their original facility.6,8 An increase in the number of patients requiring the continuation of critical care in-transit has led to a need to expand the borders of traditional intensive care beyond the confines of the hospital. Such a concept fits with the assertions of Peter Safar, a pioneer of modern critical care, who proposed that critical care should not be defined by geographic location, but rather a set of principles designed to deliver appropriate and timely care to patients who need it.9Specialised transfer services: The advent and implementation of critical care transfer and retrieval services has been the bridge to this divide, lying at the confluence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Undertaking the transfer of a patient requiring the initiation or continuation of critical care is no simple task. Variations in patient type and severity of their medical condition, as well as the expectations of the transfer team are significant. Reports regarding the transfer of patients ranging from critical neonates, to the multi-comorbid geriatric; with complex underlying surgical and medical diagnoses; involving the concomitant administration of multiple vasoactive and sedative medications; with a variety of oxygenation and ventilation requirements, are commonplace in the literature.6,8,10–16 Consequently, moving these patients from the safety and security of one facility to another is an immense logistical challenge and fraught with risks. In addition to the severity of the patients underlying condition, limitations in space, personnel and equipment, as well an unpredictable operating environment are several of the potential hazards faced during the transfer of these patients.
These hazards are evident in the incidence of adverse events found in the literature. Incorrect referral triage; inadequate transfer team; patients requiring stabilization prior to transfer; equipment and/or technical failures; adverse drug events and medication errors are amongst the most common reported events.6,8,10–17
Further to this, the movement of patients alone has in itself been shown to have an impact on a patient's baseline status, without the occurrence of negative or untoward events.10,13,15,16 As a result, patient safety and quality of care have become essential components of modern critical care transfer and retrieval services, with the role of clinical audit central to their ability to learn and improve from previous cases and events. The local solution: Despite the relatively small size of the State of Qatar, critical care transfer and retrieval has nonetheless become a necessity within the country's healthcare system. Figure 1 highlights the locations of the main hospitals. Starting in 2014, a dedicated program was initiated to facilitate the transfer and retrieval of critical care patients across the country.18 The Specialized High Acuity Adult Retrieval Program (SHAARP) is a joint initiative between the Hamad Medical Corporation Ambulance Service (HMCAS) and the Hamad Medical Corporation (HMC) Critical Care Network (CCN). It consists of a single dedicated purpose-built ambulance, manned and run 24 hours a day, seven days a week by a variety of staff from both HMCAS and the CCN and deployed primarily for the transfer and retrieval of critical care patients across Qatar.19 The program was further developed in 2016 and formalized under the Transfer and Retrieval division of the HMCAS, with dedicated HMCAS and CCN staff receiving bespoke training and continued education;18 the addition of specialized and dedicated communications staff for call taking, dispatch and monitoring; and focused governance and audit to maintain the highest quality of patient safety and quality of care.
Since then, the program has seen considerable success and uptake within the country's health system. The activity of the unit echoes much of what can be found in the literature and further reinforces the need for such a specialized service, regardless of setting (Table 1). It further highlights the importance of the relationship and cooperation between the HMCAS and CCN regarding the expertise and resources that each component adds to the overall service. This is particularly evident in the expectations of the team regarding their duties of care whilst in transit. A significant proportion of the patients transferred by the program have required the maintenance of a high-level of care between facilities, under conditions that are far more challenging than that seen in any regular hospital ward or intensive care unit (Table 2). Conclusion: In modern healthcare, to deliver a consistent and high-level critical care service in any setting, the movement of patients is inevitable. However, in order to ensure the continuum of this level of care and maintain the highest standards of patient safety and quality of care in-transit, specialized transfer services are a necessity. The multidisciplinary nature of critical care transfer and retrieval dictates the cooperation between multiple in-hospital and out of hospital specialties and is a fundamental underlying concept in the success of such services.
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Rapid response team, is it still helpful?
Authors: Sayed Tarique Kazi and Emad MustafaFor the last three decades, efforts at improving the survival rate for patients post-cardiopulmonary arrest has remained unattainable. Confronting such challenge has opened the door to devise new strategies to improve patient outcomes at the onset of subtle deterioration, rather than at the point of cardiac arrest.1 In 2006, the Institute for Healthcare Improvement (IHI) introduced the Rapid Response Team (RRT) concept, also known as the Medical Emergency Team (MET), as one of the six preventative steps needed to save the lives of patients who might otherwise die unnecessarily.2 These six recommended interventions were included in a campaign by the IHI called the 100,000 Lives Campaign. A review of the literature was conducted to assess the certainty of clinical outcomes following the implementation of an RRT service within healthcare facilities. The main clinical outcome measures found included reduction of the:
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– Incidence of cardiac arrests that occurred outside the intensive care unit (ICU),
– Total ICU admissions,
– Unplanned ICU admissions, and
– Total hospital mortality rate per 1000 discharge.3
Despite the increasing utilization of RRTs worldwide, their effectiveness in reducing hospital mortality has been debated.4 However, the purpose of an RRT service is not to improve cardiac arrest management and outcomes. The primary focus of this concept is to identify patients before they deteriorate through improving patient monitoring on general wards (the afferent component) and improving the reliability of the response to deterioration by a dedicated Critical Care Outreach Team, Rapid Response Team, or Medical Emergency Team (the efferent component).4 The reliability of such systems depends on the faultless functioning of a “chain of survival” consisting of:
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– Timely recording of vital signs,
– Improved education and mindset of staff at the bedside to recognize pathological patterns,
– Reporting of abnormalities to the efferent team,
– Timely and appropriate response by the latter,
– Repeating feedback loops.
Metrics to estimate failure rescue rates have been developed and are widely used as indicators of hospital quality. The Agency for Healthcare Research and Quality has developed a measure of failure to rescue intended to address concerns about variation in documentation among reporting institutions and the fact that other metrics of patient safety, such as mortality and complication rates, may be more a measure of patient-related factors than quality of care. Those metrics are limited to some degree in their usefulness because some patients with advanced illness simply do not want life-prolonging interventions, and some adverse occurrences are not preventable. Nevertheless, recognition of failure to rescue as a significant issue and an important quality indicator has prompted numerous studies of the underlying causes and the development of systematic approaches to address them. It is time to stop asking whether RRT “works.” Overall, the balance of evidence indicates that RRTs are effective at reducing cardiorespiratory arrest and mortality. The focus should now be more on how to improve detection of patient deterioration and promote a culture of safety.5
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Biomarkers for sepsis – past, present and future
More LessSepsis is, in many patients, very difficult to recognise, especially early on and in the elderly and those with multiple comorbidities1. This difficulty leads to delayed treatment in some, and over-treatment in others in whom bacterial infection does not exist. One large study of 2579 patients admitted to critical care for presumed sepsis showed that 13% had a post-hoc infection likelihood of “none” and an additional 30% of only “possible”2. With increasing recognition of the many detrimental yet usually covert effects of antibiotics, such agents can only cause harm when given unnecessarily. There is a pressing need for reliable, early, sensitive, and specific biomarkers to (i) indicate the presence of infection, (ii) to indicate the likelihood that these infected patients will go on to develop organ dysfunction (sepsis), and (iii) to identify which specific treatments (e.g. immunomodulatory) should be administered to which patient in terms of timing, dosing, and duration.
Infection diagnostics have traditionally relied upon Gram stain and culture; the yield is low and often several days elapse before an organism is identified, speciated, and its antibiotic resistance pattern determined. Newer molecular diagnostics are arriving at an impressive pace and offer the opportunity for point-of-care testing at the bedside to identify micro-organisms (at least, the commonest pathogens), and some indication of antibiotic sensitivity, within minutes of sampling. Remarkably, bacteria within the lung can also be imaged in real time. As an example of the power of molecular diagnostics, one study involving 529 patients in nine European ICUs demonstrated that from 616 blood culture samples, polymerase chain reaction/electrospray ionization-mass spectrometry identified a pathogen in 228 cases (37%) whereas traditional blood cultures were positive in just 68 (11%)3.
For sepsis, current biomarkers such as C-reactive protein and procalcitonin are generally fairly sensitive but are too non-specific to accurately diagnose infection as the cause of inflammation, nor to identify which infected/inflamed patients will proceed to organ failure. Many patients will thus be unnecessarily treated with antibiotics while a smaller number may be inappropriately not treated. It is unlikely that a single biomarker will yield all the necessary information so technologies that can measure multiple markers will probably be more useful. Such devices are being developed, often for point-of-care testing, and include PCR (polymerase chain reaction), lateral flow, microfluidics, and nanotechnology4,5. These promise to deliver results in 30-75 minutes at the bedside with no need for involvement of the main hospital laboratory. The challenge now is to find the best biomarkers.
Finally, for treatment selection, it has become clear that sepsis is an umbrella syndrome with many patient subsets within. Inflammatory and hyperinflammatory phenotypes have been described from a combination of clinical and biological markers. At least from retrospective studies, it appears that these subsets respond differently to fluid, PEEP (positive end-expiratory pressure), oxygen, and corticosteroids. So targeted treatment may become a reality in the not-too-distant future though prospective validation is first needed.
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What matters in shock? Flow or pressure?
More LessShock is a state of ‘acute circulatory failure’, the key feature of which is an inability for tissues and cells to get enough oxygen to meet their needs, ultimately resulting in cell death1. Shock can be classified as hypovolemic, cardiogenic, obstructive or distributive although many patients will have several types of shock simultaneously1. Although it is important to identify and treat the underlying cause of shock (e.g., antibiotics and source removal for septic shock; thrombolysis or embolectomy for massive pulmonary embolism causing obstructive shock1, hemodynamic support must be started immediately in all cases to provide a minimum perfusion pressure and prevent development or worsening of organ dysfunction. In this context, both “flow” and “pressure” are important components. Indeed, the arterial pressure is determined by blood flow and vascular tone, i.e., blood pressure = cardiac output x systemic vascular resistance. The essential aspects of shock resuscitation can be remembered using the simple VIP mnemonic: ventilate (ensure adequate oxygenation), infuse (provide adequate fluid resuscitation), and pump (administer vasoactive agents). Fluid administration should be guided by repeated fluid challenges so that patients receive enough fluid but not too much, as excess fluid can have multiple harmful effects. If hypotension is severe, vasopressors should be started early, at the same time as fluids, to increase systemic vascular resistance and thus arterial pressure. Prolonged periods of hypotension are associated with worse outcomes2. Importantly, although an initial mean arterial pressure (MAP) target of 65 mmHg may be a useful aim, this will not be optimal for all and target values should be adapted according to the individual patient, taking into account various factors including age and history of chronic hypertension. Indeed, if the MAP target is too low, resultant hypoperfusion may lead to cellular death and organ dysfunction, but a target that is too high may be associated with edema and excessive vasoconstriction as a result of higher amounts of fluid and vasoactive agents3, which may also impair organ function. Patients with circulatory shock must therefore be carefully monitored, including regular assessment of cardiac output, and treatment and targets adapted accordingly. Monitoring organ perfusion at the bedside is difficult without specific tools to assess the microcirculation. As such, we must generally rely on three “windows” that can indicate inadequate perfusion, i.e., impaired cutaneous perfusion, impaired renal function, and impaired mental status1. Plasma lactate levels can also be useful, with changes over time providing some indication of adequacy of tissue oxygenation. Although these changes are too slow to help acutely guide therapy, the trend can provide valuable information about patient status over time. If flow remains inadequate and there is no, or only a poor, response to fluids, an inotropic agent may be considered. Dobutamine is the inotrope of choice. In this context, measurement of mixed (SvO2) or central venous (ScvO2) oxygen saturation can help as it provides an indication of the balance between oxygen delivery and consumption, with low values ( < 70%) suggesting that increasing oxygen delivery could be beneficial4.
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Performing cardiac investigations after VA ECMO implementation in adults
More LessVeno-arterial extracorporeal membrane oxygenation (VA ECMO) is commenced for adult patients with severe acute cardiac failure refractory to conventional therapy or following protracted cardiac arrest refractory to cardiopulmonary resuscitation.1 Following the commencement of ECMO there are several key questions which need to be addressed.
Initial investigations are those which are designed to understand the cause of the cardiac event, gain an understanding of the consequences of the event, particularly on other organ functions and also to direct initial treatment. At this stage, consideration should be given to basic biochemistry, electrocardiography, echocardiography, coronary angiography and computed tomography.2 These investigations can explain the origin of the cardiogenic shock and direct therapy, for example stenting of culprit lesions or management of an autoimmune cardiomyopathy.
Additionally, clinical monitoring tools should be implemented to allow understanding of the consequences of the cardiac insult and the impact of ECMO. One of the key problems of peripheral VA ECMO is the increase in afterload for the native heart which prevents appropriate left ventricular emptying.3 An early understanding of left ventricular end diastolic pressure as well as left ventricular emptying can assist in planning the need for left ventricular unloading devices. Investigations including direct measurements of left ventricular pressure at the time of the coronary angiogram can give a static measure of the impact of afterload. Continuous monitoring using pulmonary artery catheterisation with measurement of pulmonary capillary wedge pressure as well as intermittent echocardiography can help identify rises in left ventricular end diastolic pressure which may result in serious complications including pulmonary oedema, pulmonary haemorrhage, left ventricular distension and left ventricular thrombosis.
Investigations or clinical monitoring is also essential to facilitate optimal patient management. Early in the course of VA ECMO, there are naturally concerns about the ability of the ventricle to empty, however during cardiac recovery there is also the potential for the heart to eject deoxygenated blood, particularly if the lungs are yet to recover. Monitoring including continuous peripheral saturation monitors, arterial blood gases and cerebral near-infrared spectroscopy can all assist in understanding the relative provision of blood to the brain from ECMO or the native circulations.4 Similarly, continuous investigations of the blood supply distal to the cannulated peripheral artery are essential. There is a substantial risk of femoral arterial thrombosis and this can be managed through the use of intermittent doppler signals for the distal vessels or through the use of near-infrared spectroscopy for the legs.4
Finally, there is a requirement for monitoring and investigation of the pump and its function/impact on the patient. This includes identification of complications such as haemolysis, microthrombosis, air embolism and disseminated intravascular coagulopathy.5 Circuit gases can also be used to demonstrate functioning of the circuit and to prevent exposure of organs to profound hyperoxia or non-physiological pH.
In conclusion, there are a number of key investigations and clinical monitoring devices which should be undertaken following the commencement of VA ECMO to both understand the cause and to predict/prevent complications.
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Management of open complicated abdomen
More LessCritically-ill patients may have their abdomens opened as a result of primary pathology (damage-control laparotomy in trauma, soiled peritoneum from perforated hollow viscus, necrotizing pancreatitis), or as treatment for abdominal compartment syndrome (defined as new organ dysfunction associated with intra-abdominal hypertension).
The incidence and implications of intra-abdominal hypertension and abdominal compartment syndrome (ACS) in particular, are currently debated.
Intra-abdominal hypertension (IAH) is defined as a sustained intra-abdominal pressure ≥ 12 mmHg. Grading is possible; Grade I = IAP 12 to 15 mmHg, Grade II = IAP 16 to 20 mmHg, Grade III = IAP 21 to 25 mmHg, Grade IV = IAP >25 mmHg. Management principles include reduction of intra-abdominal gas (NGT and flatus) and intra-abdominal fluid (the latter may be interstitial or intra-peritoneal), and ensuring the abdominal wall is as compliant as possible. Definitive management is to open the abdomen however, the benefits and use of the open abdomen (OA) approach are unclear. The rates of OA appear to be reducing worldwide.
The reduction in the incidence of ACS requiring laparostomy may be related to global changes in resuscitation targets1, rather than changes in surgical techniques. In particular, the notion of ‘fluid de-resuscitation’ may be implicated in improved outcomes.
The decision to leave the abdomen open after emergent laparotomy seems to be dependent on the surgical specialty of the operating surgeon, and is a common approach applied in victims of blunt abdominal trauma2.
Complications of the open abdomen relate mainly to nutritional status and long-term abdominal complications. The most feared abdominal complication relates to the inability to close the abdominal fascia, with associated increases in mortality, fistula formation, and ventral hernias.
Current critical care focus is on the prevention of the open abdomen. For intra-abdominal hypertension and acute compartment syndrome, medical management aimed at reduction of abdominal wall pressure and evacuation of intra-abdominal contents (including fluid) are cornerstone strategies. The use of neuromuscular blocking agents is controversial; short-term benefit may be outweighed by long-term complications.
For the de novo open abdomen, current research suggests a possible role for more aggressive early closure (primary or before day 5, latest day 8). Further research is required to confirm whether primary closure is safe. Temporary closure techniques using a combination of negative abdominal wall pressure in combination with partial mesh reduction seems to be helpful in increasing successful abdominal closure rates3.
Aggressive infection control and nutritional support after 72 hours is key. Common to both scenarios is the need for careful, judicious fluid management; organ perfusion must be optimized, but not at the expense of massive bowel and abdominal wall edema. The latter complicates healing and closure4.
A final question is whether extubating patients with an open abdomen is safe and feasible. The literature provides a resounding yes to this issue5.
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Role of the intensivist for organ donation
More LessThe shortage of organs for transplantation is a serious medical problem. More than 90% of organ donors are patients who die after the irreversible cessation of all brain function in Intensive Care Units (ICUs) but 5–10% of these patients who fulfill the criteria of brain death suffer cardiac arrest before becoming an organ donor therefore their organs can no longer be utilized1.
Reasons why a potential donor does not become a utilized donor includes failure to identify/refer a potential donor, hemodynamic instability/unanticipated, and cardiac arrest with consecutive organ damage amongst others. Because the majority of potential organ donors are in the ICU, the critical care management guided by the intensivist plays a key role. The intensivist's responsibilities include the timely identification and referral of the potential organ donor for Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), optimization of the brain-dead donor by early goal-directed management of the physiological consequence of brain death, in addition to development and implementation of protocols and clinical pathways for DCD in collaboration with the organ transplant team in the hospital2. Identification and referral should be done as early as possible and should be guided by best available evidence guidelines e.g. the NICE Clinical Guidelines “Organ Donation for transplantation”. If not yet addressed, the organ donation team will approach the family to obtain their consent for organ donation.
The clinical picture of physiological changes that follow brain death is not uniform. Severity and occurrence of dysfunctions are related to the etiology and time course of brain death. Most common are hypotension, diabetes insipidus, hypothermia, and plasma electrolyte imbalance in comparison to pulmonary edema, metabolic acidosis, cardiac arrhythmias, and disseminated intravascular coagulation3. The general management principles in the ICU regarding DBD and DCD are similar. The donor management goals shall ensure physiological homeostasis to maintain the best possible organ function at the time of organ harvesting and includes cardiovascular, respiratory, fluid, electrolyte, hormone, blood, coagulation and temperature management to maintain normovolemia, hemodynamic stability, and normothermia4. A recent prospective study investigated the effect of the implementation of a Donor Management Goals (DMG) bundle that focused on maintaining parameters like blood pressure, central venous pressure, ejection fraction, arterial blood gas, PaO2/FiO2 ratio, sodium, blood glucose with support of low dose vasopressors within normal limits. The achievement of any 7 of 9 DMGs was associated with a substantial increase in the number of organs available for transplantation5. Meanwhile, many countries recognized that the principle of organ donation should be a routine component of end-of-life (EOL) care.
By implementing strategies of early identification and evidence-based goal-directed management protocols to preserve organ function, the critical care team guided by an experienced intensivist in collaboration with the organ donation team can help to improve organ availability and quality to overcome shortage of organs for transplantation.
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Prone positioning in ARDS: physiology, evidence and challenges
Authors: Husain Shabbir Ali and Megha KambleIntroduction: Prone position has been used since the 1970s as a rescue therapy to treat severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). Despite numerous observational and randomized controlled trials showing the effectiveness of prone position in improving oxygenation, mortality benefit was demonstrated only recently in the PROSEVA study1. Intensivists taking care of patients with ARDS should be aware about the physiological changes during prone ventilation, the latest evidence available and challenges that can be encountered in managing such patients. Physiology of prone position ventilation: When a person is supine, the weight of the ventral lungs, heart, and abdominal viscera increase dorsal pleural pressure. This compression reduces transpulmonary pressure in the dorsal lung regions. The increased mass of the edematous ARDS lung further increases the ventral-dorsal pleural pressure gradient and reduces regional ventilation of dependent dorsal regions. The ventral heart is estimated to contribute approximately an additional 3 to 5 cm of water pressure to the underlying lung tissue. In addition to the weight of the heart, intraabdominal pressure is preferentially transmitted through the diaphragm, further compressing dorsal regions. Although these factors tend to collapse dependent dorsal regions, the gravitational gradient in vascular pressures preferentially perfuses these regions, yielding a region of low ventilation and high perfusion, manifesting clinically as hypoxemia. Placing a person in the prone position reduces the pleural pressure gradient from nondependent to dependent regions, in part through gravitational effects and conformational shape matching of the lung to the chest cavity2 [Figure 1]. Clinical evidence: A few large randomized clinical trials, conducted over a period of 15 years, investigated the possible benefit of prone position on ARDS outcome [Table 1]. The improvements in oxygenation apparent in most trials were not associated with improvements in mortality, suggesting that oxygenation is not itself the source of improved survival with prone positioning. Most recently, the PROSEVA study group1 enrolled 466 subjects with moderate-to-severe ARDS. Mortality at 28 and 90 days was significantly lower with prone position versus supine position (16% vs 33%, respectively, p < 0.001, and 24% vs 41%, respectively, p < 0.001). Challenges: There are only a few absolute contraindications to prone positioning, such as unstable vertebral fractures and unmonitored or significantly increased intracranial pressure. Hemodynamic instability and cardiac rhythm disturbances are some of the relative contraindications. The common complications of prone positioning are pressure ulcers, ventilator-associated pneumonia and endotracheal tube obstruction. More serious fatal events such as accidental extubation is rare (zero to 2.4% prevalence). A recent meta-analysis of the safety and efficacy of the maneuver showed that it is safe and inexpensive but requires teamwork and skill. Reports in the literature suggest that the incidence of adverse events is significantly reduced in the presence of trained and experienced staff. Thus, centers with less experience may have difficulty managing complications, but nursing care protocols and guidelines can mitigate this risk4. Conclusion: Prone position ventilation in patients with moderate-to-severe ARDS improves hypoxemia, provides mortality benefit and is relatively safe.
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Diaphragm dysfunction: weaning perspective
By Nadir KharmaWeaning is the process of successfully liberating the patient from mechanical ventilation. The majority of patients will separate from the ventilator after a successful spontaneous breathing trial (SBT).1 In a minority of patients, weaning can be challenging and prolonged. Finding the cause of weaning difficulty is crucial to minimize the rates of extubation failure and prolonged ventilation.
Diaphragm dysfunction (DD) has been described as a separate entity responsible for weaning failure with an incidence of 23–80%. It has also been associated with difficult weaning, prolonged intensive care unit (ICU) stay and mechanical ventilation, and increased ICU and hospital mortality.2 Sepsis, shock, and ventilator induced diaphragm dysfunction are important risk factors of DD. Diaphragm dysfunction has several mechanisms. Disuse atrophy and microstructural changes of the diaphragm have been described as the two cardinal pathophysiologic features.
Establishing the diagnosis of DD can be complex in critically ill patients. Bilateral anterior magnetic phrenic stimulation is widely considered as the gold standard but is only available in large research centers with limited availability. Ultrasonography of the diaphragm is a promising tool given its wide availability, affordability, and non-invasive nature. Ultrasound is operator dependent, however and it does not provide continuous monitoring capabilities. The diaphragm thickening fraction (DTF) can be calculated from measuring the end-expiratory and end-inspiratory diaphragm thickness at the bedside. It correlates well with transdiaphragmatic pressure.3 Electromyography of the diaphragm may overcome the limitation of ultrasound by offering a continuous assessment of the diaphragmatic electrical activity, but it requires the placement of a specialized nasogastric tube.
Management of DD is better approached by implementing a preventive and a curative strategy. From animal studies, allowing for spontaneous breathing on mechanical ventilation may prevent the problem. The degree of the recommended patient effort and ventilator assistance to achieve optimal balance between diaphragmatic loading and unloading are yet to be defined. Monitoring DTF while finding the optimal ventilator support level can be useful in this context. Another modality to prevent DD is diaphragm pacing applied through a transvenous phrenic nerve pacing system. Animal studies in pigs showed that this modality resulted in less diaphragm atrophy when pacing was synchronized with ventilation.4 There is an ongoing study to assess the role of diaphragm pacing to recondition and strengthen the diaphragm in difficult to wean mechanically ventilated patients (Clinicaltrials.gov NCT03107949).
Once diaphragm dysfunction is established, no specific treatments exist at this time. Other causes of weaning failure like cardiac dysfunction have to be excluded and treated. Improving respiratory load and respiratory muscle weakness imbalance is also crucial. While it appears to improve inspiratory muscle strength parameters, inspiratory muscle training has not consistently shown improvements in weaning success.5 Levosemindan showed some benefit in improving diaphragm contractility and efficiency in healthy volunteers but was later found to increase likelihood of weaning failure in septic patients. Anabolic steroids were not found to be effective in treating diaphragm dysfunction in several studies. More evidence is needed before recommending non-invasive ventilation post-extubation in all DD patients.
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Intermediate pulmonary embolism: Diagnosis and management
More LessIntermediate (“submassive”) pulmonary embolism (PE) is proven acute PE without shock but with elevated troponin, BNP, or NT-proBNP, with either contrast-enhanced chest CT or echocardiographic evidence for right ventricular (RV) dysfunction, usually enlargement. However, definitions of intermediate PE vary widely: Some allow a single abnormality of any of the five (two imaging; three biomarker) results, and some would accept normal findings in all five but ECG evidence of RV strain. The quite varied criteria means recommendations for intermediate PE management frequently are not derived from the same type of patient. Diagnosis: Intermediate PE is considered after a diagnostic CT PA-gram with filling defects. The imaging study RV:LV cavity dimensions can be measured in the same image, but a ratio >1.0 is not predictive for adverse outcomes. Abnormal interventricular septum position and reflux of IV contrast into the IVC are associated with poorer outcomes. Echocardiography can measure RV and LV cavity dimensions in the 4-chamber view, but measurements without echo contrast are unreliable. Dynamic views of the RV can show impaired contraction, and/or reduced tricuspid annular plane systolic excursion (TAPSE), and/or elevated estimated pulmonary artery systolic pressure. But in a recent study by expert investigators, 27/83 (33%) of patients presenting to the Emergency Department with persistent dyspnea but CT PA-grams negative for PE had RV dysfunction by one or more of these echocardiogram criteria1. “RV dysfunction” is prevalent in dyspneic patients; in the acute PE patient, it may not be related to the PE. Thrombolysis: A randomized trial of weight-based IV tenecteplase vs placebo2 added to heparin compared outcomes in 500 patients in each group with intermediate PE, defined as requiring CT or echocardiographic RV dysfunction and elevated troponin. At day 30 tenecteplase deaths were 12 vs 16, respectively (p = 0.42) but significantly more strokes (12; 10 hemorrhagic, incidence 2.4%) vs 1 (incidence 0.2%) (p = 0.003), and extracranial bleeds occurred in 32 (6.3%) tenecteplase patients vs 6 (1.2%), (p < 0.001). Chronic thromboembolic pulmonary hypertension (CTEPH) was 2.6% in both groups after 3 years. An accompanying editorial3 concluded: No routine systemic thrombolysis; instead, observe for deterioration, for example, shock. To reduce bleeding, catheter-directed thrombolysis (CDT) for intermediate PE (mostly case series, sometimes ultrasound-enabled catheters; up to 20 mg rt-PA) has been reported. In the only randomized study (30 patients/group), ULTIMA4, 90-day mortality (0 vs 1), RV/LV ratio, and TAPSE were the same as with anticoagulation. 24-hour pulmonary artery pressure results were superior with CDT. Recommendations: In intermediate PE, observe carefully. Bolus IV heparin 80 U/kg actual body weight during the diagnostic work-up, infuse 18 U/kg actual body weight if the PE diagnosis is proven or likely. Obtain baseline BNP or NT-proBNP and follow every 6–12 h to help assessment. If hypotension occurs, consider half- or full-dose rt-PA5. If systemic thrombolysis is contraindicated, try catheter-directed thrombolysis by mechanical fragmentation or with 10–20 mg rt-PA infusion into the most important clot.
When active bleeding, impaired hemostasis, and high bleeding risk are concerns, give IV heparin without a bolus, 200–300 U/hour, and observe 6–8 h for hemostasis. Increase by 100 U every 8 h if tolerated without excessive bleeding until 600–800 U/h, then continue until bleeding risk remits. Consider a retrievable IVC filter.
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Do not attempt resuscitation (DNAR) conversation is not only ICU responsibility: experience as an emergency physician in Qatar
By Alhady YusofIn a busy and hectic critical care setting, sometimes an ‘emergency’ Do Not Attempt Resuscitation (DNAR) conversation has to take place to prevent unnecessary ‘futile care’. Traditionally, this is the responsibility of Intensive Care Unit (ICU) doctors after discussion with family members, or by the primary care doctors after discussion with patients themselves prior to them becoming critically ill. Many critically ill patients with known ‘terminal illnesses’ brought to the Emergency Department (ED) in Qatar do not have a DNAR order. Increasingly, DNAR conversation is being undertaken by Emergency Physicians (EP), alongside ICU doctors. Often, these difficult conversations with family members occur in the ED prior to escalating resuscitation, if time permits. In Qatar, three physicians need to sign the DNAR order if they think it is clinically appropriate. Patients or their family members do not need to sign. However, hospital regulation allows it only after discussion with and agreement from them. Often, the DNAR order also includes the maximum intervention agreed. Some family members object the DNAR order, and insist on ‘full resuscitation’ and organ support, despite explanation of the poor prognosis, and the likelihood of non-curable deterioration. This review looks at the current practice, challenges and evolution of ‘emergency’ DNAR conversation in critically ill adult patients in Qatar.
There are at least two different ‘opposing’ approaches to DNAR discussion with patients (and more often the case with family members of patients in critical care setting). The most often used is the patients’ choice approach1. In some society, patients discuss openly with their doctors about their condition fairly early on in the course of their illness. When they become critically ill, a similar discussion is undertaken with family members (or surrogates). A lot of emphasis is put on personal choices and preferences. Another approach, is a physician's driven DNAR recommendation when the clinical circumstance is appropriate2. This happens more commonly when patients present to hospital in late stages of their terminal illness (or with acute deterioration) without any DNAR order. In certain societies, DNAR is not generally discussed unless the condition is acute, life-threatening and the likelihood of a meaningful recovery becomes extremely small.
Both approaches are probably the two ends of the same spectrum (see Diagram 1). Both involve risk-benefit discussion (and likelihood of success with good outcome) of cardiopulmonary resuscitation (CPR) in the event of deterioration and cardiac arrest. Having agreed on a DNAR status does not mean that the patient will get substandard care. Patients and families have to be reassured of this fact. Given the appropriate care, many patients with DNAR status recover from their acute illness episodes and are successfully discharged home after emergency hospitalization3. An appropriate DNAR order will guide the medical team (doctors and nurses) to avoid unnecessary ‘futile care’, and hopefully lead to ‘better’ personalized care for patients and their families4.
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End of life – The nurses’ perspective
By Saumya BobyIntensive Care Unit (ICU) support is provided with the aim of maintaining the vital functions, reducing mortality and morbidity in patients with a severe critical illness.1 Despite having newly developed technologies and improvement in care, the death rate in the intensive care unit remains high, ranging between 20-35%.1 The care that people receive at the end of their lives has a profound impact not only upon them but also upon their families and carers.
End of life (EOL) in the ICU is a challenge. Nature and spirituality have been superseded by all that medical science has to offer by way of technology and life support, prolonging the dying process and dictating the time of death.2
Death as it occurs in the ICU is neither simple nor natural. Caring for dying patients and their families is thought to be most stressful and painful to the nurses who constantly attend to the patients whereas other healthcare providers can visit and then walk away.3 There are only limited studies from the perspective of critical care nurses on obstacles and/or supportive behaviors that either restrict or promote good care for dying patients even though there are adequate documentation of the difficulties and inadequacies of providing EOL care to patients.3
It is well identified that the nurses have a decision making role as they act as a link between families and physicians in decisions at the end of life while interpreting and explaining information.2
It has been noted that the nursing paradigm of enhancing communication, reducing symptom burden, and supporting families are aligned with the common domains of EOL care.4 The study using the grounded theory approach to formulate a conceptual framework of the nursing role in EOL decision making in an ICU setting concluded that the core concept, supporting the journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses describe being present with patients and families to validate feelings and give emotional support, nursing work, while bridging the journey between life and death, imparting strength and resilience and helping overcome barriers to ensure that patients receive holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.2 Thus involving the nurses in the multidisciplinary decision making of EOL care will be beneficial.
Nurses play a very important role in EOL care by providing family care and collaborating with the rest of the medical team.5 Working as a nurse within the wider ICU team requires good collaborative and communication skills and few studies have focused on how we foster these skills to enhance EOL care in the ICU. Little is known about the role of nurses in end of life in the critical care setting, and therefore a grounded theory study in this area is needed to further understand this important role.2
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Pediatric sepsis update
More LessPediatric sepsis comprises a spectrum of disorders that result from infection by bacteria, viruses, fungi, or parasites. Sepsis ranges from bacteremia, with early signs of circulatory compromise to complete collapse with multiple organ dysfunction and death. Early recognition improves outcomes for infants and children. Over the past two decades, sepsis has been defined and redefined with modifications for the pediatric population. The most recent iteration, complementing the NICE guideline (NG51) “Sepsis: Recognition, diagnosis and early management”, was published in 2017.1
Pediatric severe sepsis usually is community-acquired (57%) with the respiratory tract as the primary site of infection. Mortality rates associated with sepsis and septic shock in patients admitted to the pediatric intensive care unit are 5.6% and 17.0%, respectively.2
The SIRS adult criteria have been modified to produce pediatric-specific definitions. Per the 2017 Sepsis-3 guidelines, sepsis in adults is no longer based on the SIRS criteria, rather it is defined as an infection with at least one organ dysfunction. Although it may change in the future, the definition for the pediatric population remains based on the SIRS criteria due to weak evidence.3,4 Although not included in the definition of sepsis, hyperglycemia, altered mental status, and high lactate, are highly suggestive of sepsis and should be considered when evaluating a patient.
Risk factors for pediatric sepsis include less than one month of age, serious injury, chronic medical problems, immunosuppression, indwelling devices, and urinary tract abnormalities. Sepsis should be in the differential diagnosis in children with persistently abnormal vital signs such as tachycardia that is often missed and attributed to other causes. Hypotension is a late finding in children; the diagnosis of shock cannot be based solely on this finding. Unlike adults, previously healthy children can compensate extremely well during hypoperfusion states and do so for relatively long periods resulting in sudden decompensation.2
Timely response to sepsis is vital to survival. Vascular access needs to be obtained, fluids administered (minimum of 60 ml/kg), broad spectrum antibiotic coverage and initiation of inotropic support in fluid refractory shock need to occur within the first hour. Hydrocortisone should be considered with catecholamine-resistant shock and if at risk for absolute adrenal insufficiency. Laboratory diagnostics such as white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) are often nonspecific. More novel tests such as lactate and procacitonin are more specific clinical adjuncts that will support diagnosis, monitor, and trend a child's progress.1,5
Key recommendations of the 2017 guidelines highlighted the importance of bundles: “recognition bundle” with trigger tools for rapid identification; “resuscitation and stabilization bundle” to increase adherence with best practice principles; and a “performance bundle” to identify gaps and barriers in the system.1
Not every child with fever will have a serious infection leading to sepsis. Delays in recognition and management will worsen the prognosis significantly; early recognition is crucial. Any child with a suspected infection, persistently abnormal vital signs, or a concerning exam after antipyretics and intravenous fluids should be investigated and treated for sepsis. Rapidly changing standard of care makes sepsis a critical diagnosis for clinicians.
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Current Trends in Pediatric ARDS
Authors: Ikram U. Haque and Jai P. UdassiPediatric acute respiratory distress syndrome (PARDS) incidence is reported between 2.95 to 12.8 cases per 100,000 person years,1,2 which is lower than in adults but remains one of the most challenging form of lung diseases for a Pediatric Intensivist. Application of the adult ARDS definition is limited in pediatrics due to differences in risk factors, etiology, pathophysiology, hard to obtain PaO2 values, and lower levels and variation of PEEP utilization. To address these limitations, to promote early recognition and diagnosis of PARDS, and to improve prognostication and stratification of disease severity, the Pediatric Acute Lung Injury Consensus Conference (PALICC) published the first definition for PARDS in 2015.3
This definition (Table 1) kept the criteria of onset within seven days of a known clinical insult and the presence of respiratory failure not fully explained by cardiac failure or fluid overload. It eliminated the term acute lung injury, excluded bilateral infiltrate, and stratified severity of PARDS based on the oxygenation deficit as mild, moderate, and severe. Either oxygenation index or the oxygen saturation index (when arterial blood gas is not available) can be used to assess the degree of hypoxemia. Non-invasive ventilation is now included for continuous positive airway pressure of more than 5 cm H2O. Furthermore, PALICC included recommendations for defining PARDS in children with preexisting chronic lung disease, cyanotic congenital heart disease, and left ventricular dysfunction.
The PARDS management guidelines are based on very limited pediatric data and are largely based on expert opinions.3 For ventilatory management, no mode of ventilation is found to be superior, patient-specific tidal volumes per ideal body weight according to disease severity are recommended (3–6 mL/kg for patients with reduced and 5–8 mL/kg for patients with better-preserved compliance). In the absence of transpulmonary pressure measurements, plateau pressure should be limited to 28 cm H2O and 29–32 cm H2O during increased chest wall elastance. Moderately elevated PEEP to 10–15 cm H2O should be titrated in severe PARDS to the observed oxygenation and hemodynamic response. The oxygenation goal for mild PARDS (PEEP < 10) is 92–97% and severe PARDS (PEEP >10) 88–92%, although in some patients, < 88% can be considered with oxygen delivery monitoring. Permissive hypercapnia with a pH of >7.15 is the goal except in severe pulmonary hypertension, intracranial hypertension, select congenital heart lesions, significant ventricular dysfunction with hemodynamic instability, and pregnancy. Recruitment maneuvers by slow incremental and decremental PEEP steps may be used for severe hypoxemia. High-frequency oscillatory ventilation remains as an alternative ventilatory mode for patients with moderate-to-severe PARDS. There is not enough evidence to support the routine use of inhaled nitric oxide, steroids, or prone positioning for PARDS at this time.3
Since the publication of the new definition, several studies comparing the previous definitions to PALICC suggest that the PALICC definition can not only identify more patients with PARDS but it is also better at risk stratification for mortality.4,5 Despite decades of research and experience of managing PARDS, there remains a lack of definitive clinical evidence in Pediatrics. Further pediatric research is needed to gain more insight and to improve outcome of PARDS.
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Promoting NIV using ICEMAN methodology
Authors: Manu Sundaram, Ashwath Ram, Alberto Medina and Marti Pons-OdenaOne of the main reasons for children needing hospital admission is the need for respiratory support and monitoring. Intubation and ventilation has been the standard method of supporting patients in respiratory failure. With better ventilators and interfaces many of these children with respiratory failure could benefit from non-invasive ventilation (NIV). The main advantages of NIV over its invasive counterpart are reduced need for sedation, avoiding laryngeal and tracheal injuries, reducing nosocomial infections, and shorter length of stay.1,2
NIV can be used for acute conditions. Studies have shown that NIV is more successful in type 2 respiratory failure compared to type 1 respiratory failure as in type 2 respiratory failure, a failing pump is replaced by another pump i.e., NIV machine.3,4
With improvement in technology NIV has emerged as a core therapy in the management of patients with acute and chronic respiratory failure. Use of NIV has not spread worldwide. Even in the countries where they are being used, there is huge variability in the use of NIV. This reluctance in usage could be partly explained by the lack of adequate scientific literature in children concerning this technology.
The first thing to do to overcome this barrier is to create an understanding and familiarity of this technology, resulting in more usage of NIV which has been shown to improve the quality of care and reduce cost of healthcare.
A FAST-NIVT (Forwarding Advanced Simulation Training in Noninvasive Ventilation Therapy) project supported by the Respiratory group of ESPNIC (European Society of Pediatric and Neonatal Intensive Care) has developed blended courses (online and face to face) for attendees and for NIV trainers in order to promote the teaching and learning of NIV around the world.
As an extension of this project we have developed a structured algorithm with the acronym ICEMAN (Figure 1) and used it to train our clinicians in the judicious selection of patients, contraindications and equipment used for NIV.2 This approach helps the teams to recognize failure of non-invasive ventilation, troubleshoot hypercapnia and hypoxemia, manage asynchrony and plan for weaning or escalation of care using algorithms.
We have conducted workshops globally to provide clinicians with best practice recommendations and guidance about how to best deliver non-invasive ventilation to patients who sometimes need this lifesaving technology. By attending this workshop, delegates would be able to understand the various indications, NIV options, modes of delivery, effective monitoring, and analysing failures which will definitely go a long way in providing this care more effectively with less failure.
All the workshops are led by trained educators who are experienced practicing paediatric intensivists, neonatologists, and pulmonologists with an extensive NIV experience. To make learning fun and to encourage participation, high-quality learning materials and skill stations have been tailored to the needs of each group. This methodology has been successfully used to train the next generation of clinical champions.
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Approach to circulation after cardiac surgery in children
Authors: Jai Udassi and Ikram HaquePediatric intensivists are called to patient bedsides in the pediatric cardiac intensive care unit (CICU) after congenital cardiac surgery for low blood pressure (BP) and/or poor perfusion, acute change in heart rate (HR) or rhythm, surgical site bleeding or increased chest tube output, anuria or oliguria, oxygen desaturation less than expected or metabolic acidosis with rising lactic acid and base deficit. Causes of acute circulatory failure after cardiac surgery are divided into four categories which must be considered when approaching the patient in CICU (Table 1).
Assessing cardiac output in CICU remains challenging, hemodynamic parameters are usually monitored, along with physical examination, i.e. HR, BP, right and left atrial pressures. There are surrogate markers i.e., mixed venous saturation, brain and renal NIRS, toe temperature, urine output, and then laboratory workup to determine acidosis due to end-organ dysfunction. Echocardiography can confirm low cardiac output syndrome (LCOS) occurs after cardiac surgery with the following major indicators; abnormal ventricular-vascular interaction after bypass, the functionally univentricular circulation, abnormal diastolic function after surgery to the right heart and residual anatomic lesions.1
The limited support tools that are available to manage circulatory failure post cardiac surgery in the CICU are the following: Medications: High labile pulmonary vascular tone (PVR) occurs in patients with pulmonary over-circulation i.e., ASD (atrial septal defect), VSD (ventricular septal defect), PDA (patent ductus arteriosus) and AV canal (atrioventricular canal). Pulmonary venous hypertension, i.e. TAPVR with obstruction, HLHS with restrictive atrial communication and in the univentricular heart after Norwood, shunt or PA band has unstable PVR. Functionally univentricular hearts don't tolerate increased SVR and at the same time, decreased SVR may not be desirable for patients who have fixed systemic or pulmonary obstruction. There are a wide variety of medications to use, but essentially two, milrinone2,3 and epinephrine are very important and widely used. Milrinone is routinely used after cardiac surgery to minimize the LCOS, which works in a receptor independent manner and is synergistic to beta-adrenergic ionotropic effect. Most patients benefit from low dose epinephrine for decreased cardiac function. Nitroprusside is effective where after-load is high, a low dose should always be started titrating to the optimal BP. Generally, there is no role of dopamine in these patients.4Ventilation-cardiopulmonary interaction: Ventilation at functional residual capacity needs to be targeted. Managing rhythm: Recognition of rhythm is a crucial aspect of care. It is equally important to pay attention to the appropriate heart rate. Extracorporeal mechanical support: The last resort is to put the patient on extracorporeal membrane oxygenation.
In summary, the past two decades have seen important advances in our understanding of the circulatory physiology of infants and children post cardiac surgery. When approaching the patients with cardiovascular dysfunction, it is essential to approach the cardiopulmonary system in its entirety, rather than consider the heart, lungs, or peripheral circulation as isolated elements. Working towards one common goal of optimizing systemic oxygen delivery and emphasizing anticipatory intensive care tailored to individual patients with the need for early, targeted investigation and intervention is essential when patients are not progressing as expected.
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Optimizing knowledge and skills through protocol-based ECMO management and simulation-based training: A novice clinician's perspectives of a successful ECMO program
Authors: Mohammed Elkhwad, Norita Gongora and Anna Vi GarciaBackground: Starting a new extracorporeal membrane oxygenation (ECMO) program requires synergizing different organizational aspects and extensive training of a core team to deliver care safely.1,2 Sidra Medicine, a newly opened facility in Qatar, started accepting acute inpatients and activated its ECMO program in 2018. The aim of this quality review is to evaluate the training of ECMO Specialists through benchmarking our ECMO program mechanical complications to the Extracorporeal Life Support Organization (ELSO) data. Methods: The hospital trained ECMO Specialists (experts and novices) come from different parts of the world with varying degrees of knowledge and experience and use a comprehensive training program based on the ELSO guidelines for ECMO training and continuous education.3 This program was delivered over a two-year period to all ECMO team members and included: multiple conferences on key ECMO topics; basic wet labs and emergency drills including the change of different components, and; immersive simulation-based training (SBT) on a modified neonatal manikin (Figures 1 and 2). These face to face interactions, in small groups, with different critical scenarios were followed by debriefing.4,5 SBT sessions started before the opening of the acute unit and continued after the acceptance of the first ECMO patient. Immersive SBT sessions occur monthly and include minor and major troubleshooting, de-airing, priming, circuit change, oxygen failure, pump failure, and other problems that can be encountered during ECMO runs.
All ECMO Specialists, both experts and novices, completed a full ECMO training program and had gone through the Sidra ECMO certification examination before handling ECMO patients. They were evaluated and certified using a checklist assessment tool and with skills having to be demonstrated competently by the candidates. Novice clinicians were initially ECMO bedside nurses and as they became familiar with the ECMO daily routine and learned the protocols and policies, they started caring for patients as ECMO Specialists.
We retrospectively reviewed collected data of technical complications for the 13 patients who have received ECMO therapy since program activation. We analyzed ECMO mechanical complications and benchmarked them with ELSO registry data in corresponding categories to evaluate the training of ECMO specialists and our ECMO program infrastructure. Result: The Sidra ECMO program has now trained a total of 20 ECMO Specialists (experts and novices). Out of the 13 novice clinicians who volunteered to be trained, 8 successfully became ECMO Specialists.
There has been a total of 13 patients on ECMO (Table 1). One of these was the first successful neonatal respiratory ECMO patient in Qatar. Over the 13 cases, minor mechanical complications and usual circuit clots were experienced. There was no pump failure or oxygenator failure encountered. Conclusion: SBT is a valuable ECMO educational approach. It offers the opportunity to practice technical skills repeatedly and to become proficient in high-risk/low frequency events while avoiding harm to patients. Using consistent and continuous training is the key for the success of the ECMO Specialist's model. This is a limited study due to the low number of patients, but as ECMO is a low-volume/high-risk procedure, it still highlights the benefits of simulation in establishing new ECMO programs.
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Advanced hemodynamic monitoring in critically ill neonates
By Samir GuptaThe neonatal circulation is unique due to the presence of fetal shunts. With the advances in biomedical technology, the assessment of sick newborn infants has improved significantly. It allows to collect, store and analyze the complex physiometric data and provides a foundation for advances in diagnosis and management of neonatal cardiovascular compromise. This could allow the clinician to have objective information to compliment the clinical assessment. Additionally, serial assessments and trending of measured parameters provides longitudinal information on disease pathophysiology and the response to treatment.
The advanced hemodynamic monitoring however has to be structured and focussed to get the relevant information to compliment clinical signs and symptoms. It however has an inherent risk of inappropriate or over-treatment leading to a state of confusion. The following questions should thus be addressed at the outset:
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1. Objectives of assessment and goal of therapy
2. Available techniques and processing information
3. Point assessment vs continuous assessment
4. Invasive monitoring vs non-invasive monitoring
When utilising these techniques, the limitations of individual devices and the interaction between them should be known. As compared to point-of-care assessment, when non-invasive monitoring devices are used, the trending of data from them with simultaneous single screen longitudinal display of values is helpful for diagnosis of disease and assessing response to treatment (Figure 1).2 The examples are continuous cardiac output, blood pressure, central venous pressure, pulse oximetry and near infrared spectroscopy. The trending of heart rate monitoring has already been utilised for early detection of sepsis using HeRO monitor. There has been interest in continuous amplitude integrated EEG but so far it is limited to research trials.
We compared measurement of cardiac output with echocardiography with non-invasive cardiac output monitoring. We observed that absolute values were different but the trend on longitudinal assessment was comparable. This could be due to the fact that non-invasive cardiac output assessment methods utilise indirect techniques such as electric velocimetry, arterial pulse contour analysis etc. Using an example of a baby with septic shock, one can understand how the hemodynamic monitoring can guide initial management.3
BP = cardiac output (CO) x systemic vascular resistance (SVR) (Figure 2) 4
If a patient has low CO, high SVR and normal BP, the choice of treatment is inodilators e.g., milrinone. If CO, SVR and BP are all low, commence treatment with norepinephrine and add epinephrine. If high CO and low BP and SVR, give fluid bolus initially and titrate therapy.
The integration of advanced hemodynamic monitoring in clinical care is akin to whole genome sequencing where a large amount of information is gathered which requires processing. Utilising this information is a challenge at present but it has the potential to open gateways for precision medicine.5
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Delirium in the PICU
By Tejas MehtaIntroduction: Delirium is a well-documented problem in the adult population however, its importance in the paediatric population has evolved recently with the development and validation of reliable paediatric delirium (PD) assessment tools. Definition: The key feature of delirium is an alteration in both cognition and arousal. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)1, defines delirium as a noticeable change in the patient's neurocognitive baseline with an acute disturbance in attention, awareness, and cognition, and is thought to be a direct result of another medical condition rather than due to an established/evolving neurocognitive disorder. Epidemiology: The overall prevalence of delirium in PICU ranges from 4% to 29%, with a recent multi-institutional PD study assessing 994 children for delirium in 25 different PICUs reporting a prevalence of 25%.2 Higher rates have been reported in children < 5 years of age.3 A PD prevalence of 49% was found in a paediatric cardiac ICU population. A prevalence rate of 27% was described in a postoperative paediatric population (delirium incidence of 65% within 5 days after surgery).3Pathophysiology: Many hypotheses have been proposed. The neuroinflammatory hypothesis suggests that systemic inflammation leads to endothelial activation, enhanced cytokine activity, and infiltration of leukocytes and cytokines into the central nervous system (CNS), producing local ischemia and neuronal apoptosis. The neurotransmitter hypothesis suggests that dysregulation of neurotransmitters like acetylcholine, dopamine, and gamma aminobutyric acid leads to the development of delirium. The oxidative stress hypothesis suggests that hypoxia coupled with increased cerebral metabolism, leads to the production of reactive oxygen species that cause global CNS dysfunction.3Risk factors: Risk factors are divided into predisposing and precipitating factors many of which are modifiable (Table 1).3Presentation: PD presents in three major subtypes. Hyperactive delirium is characterized by agitation, restlessness, hypervigilance, and combative behaviour, hypoactive delirium is characterized by lethargy, inattention, and decreased responsiveness and mixed type delirium which exhibits aspects of both hyperactive and hypoactive delirium.1 Hypoactive and mixed type delirium are common presentations in children followed by hyperactive variety. Hypoactive delirium can be easily missed without appropriate screening and diagnostic tools for assessment.3PD screening tools: Various screening tools have been developed to detect PD with their advantages and limitations (Table 2). Treatment: Management of delirium involves a multidisciplinary stepwise approach (Figure 1)3 including the management of the underlying medical illness, minimizing iatrogenic triggers, and optimizing the PICU environment. Pharmacotherapies are indicated if delirium persists and a child's agitated behaviour is distressful or interferes with medical care. Haloperidol, risperidone, and quetiapine have been used safely in children.5Outcome and prevention: PD is associated with increased length of mechanical ventilation, increased hospital stay, higher resource utilization, increased healthcare costs, and increased mortality. PD is a hospital acquired complication which can be prevented by using analgosedation approach with the goal to optimize pain and minimize sedation, minimizing iatrogenic factors, early mobilization, and involvement of family members in daily care.3Conclusion: PD is an important underrecognized issue in the PICU which needs to be prevented, detected early using screening tools, and managed using a multidisciplinary team approach.
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Concept of neuroprotective NICU
Authors: Mohammed Gaffari and Pranay JindalNeurodevelopmental outcomes are of paramount importance for every clinician as the survival rates of term and preterm babies have continued to improve. We aim to provide a framework for developing a Neuroprotective Neonatal Intensive Care Unit (NICU) by describing five main domains below. We achieve this in our NICU by a multidisciplinary team consisting of neonatologists, respiratory therapist, occupational therapist, physiotherapist, social worker, pharmacist, and a dietician. This approach needs to be individualised for each unit based on the resources and services available.
I. Neuro assessment: clinical neuro assessment remains the most important tool with strong predictive value for long-term outcomes. It is important to develop other tools of assessment like comfort and pain scoring. We use COMFORTneo scale as a standard of care.1 Neuroimaging is another important factor as part of the assessment. We have a local guideline to decide on the frequency and the timing of the neuroimaging such as cranial ultrasound and MRI.
II. Neuroprotection: antenatal magnesium sulphate and antenatal steroids have become an established treatment in most units.2 Interventions like total body cooling have significantly improved the outcomes for babies with hypoxic ischemic injury. One challenge faced in these babies is the ability to provide active cooling during transport when these babies are born outside cooling centres. Optimal nutrition is another important element for the developing brain. We developed neonatal nutritional guidelines in collaboration with the clinical pharmacist and a dietician. Introduction of starter parenteral nutrition bags for out of hours use in line with evidence-based feeding guidelines are known to improve the outcomes. We practice the golden hour protocol for all babies born before 28 weeks gestation and have introduced intraventricular haemorrhage (IVH) prevention bundles3 for the same cohort of babies. Even though individual components of these bundles do not have strong evidence, there is some benefit when these interventions are offered as a bundle. Our care bundle involves midline positioning, using log roll, minimal handling, maintaining normothermia, avoiding IV boluses, and maintaining normal CO2 levels etc.
III. Neuromonitoring: tools like amplitude-integrated electroencephalogram (aEEG), near-infrared spectroscopy (NIRS), and onsite MRI are gaining popularity. eEEG should be routinely used in hypoxic ischemic encephalopathy (HIE) babies when available. All team members should be trained in its application and interpretation. NIRS is a developing modality used by only a few units to monitor the cerebral oxygenation. We have recently started to pilot these machines.
IV. Neurodevelopment: the environment of the NICU has been shown to affect the developing brain. Strategies should be developed to optimise babies sleeping by reducing lighting and noise levels. We use positioning tools like boundaries and midliners as part of their neurodevelopment.
V. Neurointervention: we use therapeutic techniques like auditory, tactile, visual, and vestibular (ATVV) stimulation.4 It is an evidence-based technique used to increase alertness in medically stable preterm infants. We use Prechtl's Qualitative Assessment of General Movements observational tool.5 It is the most predictive tool (98% sensitivity) for detecting cerebral palsy. This helps provide targeted treatment at an earlier stage.
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The critically ill mother: Recognition and management (who, where and how?)
More LessThere is an ongoing debate about the management of the critically ill mother, notably with regards to who should manage this group of patients (the intensivist, the obstetric anaesthetist, or the obstetrician?) and where is the ideal place to manage them (labour ward, obstetric high dependency unit or the intensive care unit?). To make the most appropriate choice, an understanding of how to recognise maternal critical illness is paramount. Using the modified early obstetric warning system score (MEOWS) for obstetric patients is a useful tool 1. MEOWS looks at additional parameters to the standard early warning systems parameters with modified triggers to suit the altered physiology in the pregnant patient. Other predictors like APACHE and SOFA scores may also be used to predict maternal mortality 2. Data from several national audit and surveillance programs such as MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries across the UK) 3, UKOSS (The UK Obstetric Surveillance System), and ICNARC (Intensive Care National Audit & Research Centre) are used to aid the understanding of why mothers die in childbirth and up to six weeks postpartum and which critically ill mothers are admitted to the intensive care unit and the reason for their admission 4. Audit reports show that a significant number of deaths reported in the maternal mortality reports are associated with suboptimal care. There is a great need for an evidence-based triage system for the critically ill obstetric patient in order to help clinicians direct them to the appropriate level of care and avoid situations of suboptimal care. Regionalizing maternal critical care may help develop this triage system by increasing the exposure to such patients. Deciding on who should manage these patients will depend on the level of training and expertise of the team members involved in the management on how to detect an acutely deteriorating mother. The team members should include obstetricians, anaesthetists, intensivists, intensive care nurses and midwives. The training can be achieved using different educational approaches that are competency-based to improve the knowledge and skills in detecting signs of deterioration in order to take the appropriate actions. Multidisciplinary teams should train together using simulation-based learning focusing on human factors and communication skills 5. Deciding on where these patients should be managed will depend on the level of organ support and monitoring available as well as the access to support services such as obstetric and neonatal services, regardless of what the terminology of that location is. The different models of delivering care to the critically ill obstetric patient with the different requirements for these areas are highlighted in Table 1. Taking all the previous factors into consideration will help find the answer to the WHO, WHERE and HOW question.
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Delirium in the ICU
Authors: Jo Ellen Wilson and Eugene Wesley ElyIntroduction: Delirium, the most prevalent form of acute brain dysfunction in the Intensive Care Unit (ICU) is characterized by inattention, changes in cognition and at times thought and perceptual disturbances (e.g., delusions and hallucinations). Recent estimates of delirium prevalence suggest around 70% of patients on mechanical ventilation will experience delirium during their critical illness and almost a third of days in the ICU are days spent with delirium1,2. There are at least three distinct motor subtypes of delirium: hypoactive (decreased movement), hyperactive (increased movement and at times agitation) and mixed (features of both). The hypoactive form predominates, is under-diagnosed and is associated with worse outcomes. Recent work has suggested that another psychomotor disturbance, catatonia may co-occur in up to a third of patients with delirium in the ICU3. Risk factors: Risk factors for the development of delirium include: pre-existing dementia, advanced age, hypertension, pre-critical illness emergency surgery or trauma, increased severity of illness, mechanical ventilation, metabolic acidosis, prior delirium or coma and use of certain delirium potentiating drugs such as anti-cholinergic and sedative hypnotic medications. Mechanisms: Exact mechanisms leading to the development of delirium are unknown, however early evidence suggests neural disconnectivity of the dorsolateral prefrontal cortex and the posterior cingulate cortex. Reversible reduction of functional connectivity of subcortical regions and neuroinflammation leading to hippocampal and extra-hippocampal dysfunction, may play potential roles. Overall all brain volume loss and disruption in white matter tracts may be associated with new onset dementia in survivors of critical illness. Due to the heterogeneous phenotype of delirium, there may be multiple causative neurobiological mechanisms contributing to its development, instead of one unifying pathway. Morbidity and mortality: Delirium is associated with significant morbidity and mortality. Much of the critical care literature about delirium has focused on the exposure of delirium and its relationship with acquired disabilities, as well as its effect on in-hospital and post-discharge excess mortality. Delirium is known to be predictive of new-onset dementia4, depression, excess mortality, longer lengths of stay, institutionalization at discharge, inability to return to work and increased cost of care in the hospital. Prevention and treatment: Despite scant evidence, antipsychotic medications have historically been the treatment of choice for delirium, however recent findings suggest that typical and atypical antipsychotics have no effect on delirium duration in the ICU5. As delirium is characterized by alterations in the sleep wake cycle, some studies have explored the role of melatonin or ramelton in the prevention or treatment of delirium, with early promising results. Non-pharmacological interventions such as complete adherence to the ABCDEF (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) bundle have shown benefit in reducing delirium prevalence in the ICU2.
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Multimodality monitoring in neurocritical care
More LessMonitoring the health of an injured brain is essential to forewarn neurological worsening and to gain insight into the pathophysiology of a complex disorder.
Clinical examination remains a cornerstone in monitoring patients with brain injury. The Glasgow coma score (GCS) is widely used but lacks information regarding brain stem functions like pupillary reaction and shows moderate inter-observer reliability. However, despite these shortcomings, GCS remains a robust indicator of the need for surgery and prognosis after cardiac arrest, hypoxic brain injury, and posterior circulation stroke. A new scoring system called Full Outline of Unresponsiveness has been proposed and shows excellent inter-observer reliability and includes points concerning brain stem functions.1
The most commonly used monitoring modality is intracranial pressure (ICP) monitoring. ICP shows threshold physiology where the outcome of the patients changes after a threshold of 20 to 25 mmHg. Refractory ICP is a good predictor of mortality but not of the functional outcome after traumatic brain injury.
Brain injury causes varying degrees of disruption to cerebral blood flow and its autoregulation. Studying autoregulation provides a useful strategy for targeting cerebral perfusion pressure close to the autoregulatory range. Transcranial Doppler and ICMplus (Intensive Care Monitoring) are used to study autoregulation. ICMplus is a software-based tool that studies the correlation between slow changes in mean arterial pressure and ICP to evaluate the state of autoregulation throughout the duration of ICP monitoring.2
Brain tissue oxygen measures the partial pressure of oxygen in the extracellular fluid of the neural tissue. Reduction in brain tissue oxygen is a marker of cellular distress. A phase 2 trial on brain tissue oxygen monitoring demonstrated the safety and feasibility of the protocol-based management of brain tissue oxygenation and ICP, and a trend towards lower mortality and improved functional outcome in patients treated with combined oxygen and ICP protocol.3
Microdialysis is a point of care test that monitors substrate delivery and metabolism at the cellular level. The lactate-pyruvate (LP) ratio is an indicator of the redox state of cells and a high LP ratio is associated with an unfavourable outcome.4
The electroencephalogram (EEG) is used in critical care for monitoring sedation and diagnosis of seizure activity. EEG is a complex signal which requires advanced training and skills for interpretation. Novel EEG-based monitors are aimed at simplifying the signal for straightforward interpretation by bedside medical professionals. Cerebral function monitor (CFM) is a compressed single channel amplitude integrated EEG monitor mainly used for the detection of status epilepticus and burst suppression during thiopentone infusion. A novel technique that uses direct electrodes applied on the cortical surface called Electrocorticogram (ECoG) shows spreading depolarisations on the cortical surface that are caused by loss of ionic homeostasis and substrate delivery.5 These depolarisations are a sensitive indicator of impending neuronal death and may serve as a target for novel mechanistically oriented therapies.
Detection, prevention, and monitoring of secondary cerebral insults that alter the prognosis from the injury, remains at the centre stage in neurocritical care. In the future, integrated informatics derived from multimodality monitoring will play a pivotal role in clinical decision algorithms.
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Adrenaline in cardiac arrest
Authors: Nicholas Raymond Castle, Ian Lucas Howard and Ian Ronald HowlandThe use of adrenaline during a cardiac arrest is well-established and supported by international guidelines. However, recent studies1–2 have questioned the appropriateness of adrenaline administration whereas other papers indicate that any benefit from adrenaline maybe time-sensitive.3–4
Two recently published studies have both challenged the use of adrenaline during resuscitation and whilst both papers used different methodologies they demonstrated similar results. The Paramedic 2 study1 was a placebo-based randomised control trial whereas the paper by Loomba et al.,2 used a meta-analysis of 14 peer-reviewed publications recruiting 655,853 patients, 7.4% of whom received adrenaline. Neither study was able to demonstrate any meaningful survival benefit associated with adrenaline administration (Table 1 and 2). However, both studies noted poor neurological outcome in post-cardiac survivors. It is noteworthy that both of these studies used different, but validated,5 neurological scoring systems (either the Modified Rankin Scale or the Cerebral Performance Category).
Whilst there is an acceptable correlation between the Modified Rankin Scale or the Cerebral Performance Category (Table 3) there is a degree of variation.5 This variation is partly due to what the two scales accept as being a good neurological outcome as well as an inbuilt degree of subjectiveness of any assessment of neurological status.5
Whilst The Paramedic 2 study1 and Loomba et al.,2 meta-analysis demonstrated no benefit of adrenaline, studies by Goto et al.,3 and Donnino et al., (adults)4 have published contradictory findings. Importantly Donnino et al.,4 reported improved neurological status in non-shockable cardiac arrest when adrenaline was administered.2 However, to date no study has demonstrated a benefit of adrenaline when used to treat shockable cardiac arrest.
Interestingly both Goto et al.,3 and Donnino et al.,4 indicated that any benefit from adrenaline administration was time-sensitive. Goto et al.,3 noted that the optimal time for adrenaline administration was < 9 minutes. Whereas, Donnino et al.,4 reported on the impact of increasing time delay to the first dose noting that when adrenaline was administered < 1 minute of confirmation of cardiac arrest, 12% of patients survived, but that this dropped to 9% after the fourth minute and was down to 7% after seven minutes (p < 0.001). The findings of Goto et al.,3 and Donnino et al.,4 represent a clinical challenge. Notably, during the Paramedic 2 study the average time of administration of adrenaline was approaching 20 minutes (6.6 minutes response time and 13.8 minutes) raising the question would the results of Paramedic 2 have been different if adrenaline was administered faster and whether adrenaline should only be administrated in witnessed cardiac arrest?
The routine use of adrenaline as the mainstay of resuscitation is being challenged, especially with regards to long-term patient survival and its role in the management of shockable cardiac arrest. However, in specific patients, when given early, adrenaline may still have a role to play in resuscitation. The 2020 International Resuscitation Guidelines are eagerly awaited.
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Prognostication in comatose survivors of cardiac arrest
More LessIntroduction: Hypoxic-ischemic encephalopathy (HIE) is the leading cause of death in comatose patients after cardiac arrest resuscitation.1 Poor neurological outcome is defined as death from neurological cause, persistent vegetative state, or severe neurological disability which is predicted in these patients by assessing the severity of HIE. Background: The most commonly used indicators of severe HIE include a bilateral absence of corneal and pupillary reflexes, bilateral absence of N2O waves of short-latency somatosensory evoked potentials, high blood concentrations of neuron-specific enolase, unfavorable patterns on electroencephalogram, and signs of diffuse HIE on computed tomography or magnetic resonance imaging of the brain.
Current guidelines recommend performing prognostication no earlier than 72 hours2 after return of spontaneous circulation in all comatose patients with an absent or extensor motor response to pain, after having excluded confounders such as residual sedation that may interfere with clinical examination. A multimodal approach combining multiple prognostication tests are recommended so that the risk of a false prediction can be minimized. Materials: Neuroprognostication is vital and yet continues to be one of the most controversial topics in post-resuscitation care. Specifically, concerning HIE, the 2006 practice parameters of the American Academy of Neurology provide specific recommendations for the prognostication of neurologic outcomes for cardiac arrest survivors not treated with therapeutic hypothermia (TH).
To date, there is no adequate paradigm for prognostication in HIE treated with TH.3 Clinical examination including the presence or absence of brainstem reflexes, motor responses and absence of myoclonus were traditionally used to predict a favorable prognosis. Electrophysiologic testing in the form of somatosensory evoked potentials (SSEP), the serum biomarker neuron-specific enolase (NSE), as well as neuroimaging, have been employed as additional tests to attempt to improve the predictive accuracy of neuroprognostication. However, what limited certainty these tests and parameters provided has become even more questionable in the setting of therapeutic hypothermia. The use of sedatives and analgesics adds a degree of uncertainty given unpredictable drug effects on patients’ neurologic status.
EEG, SSEP are the most common electrophysiological modalities utilized in neuroprognostication.4 EEG has been evaluated in the prognostication of cardiac arrest survivors and has also led to some essential clinical discoveries. The 2006 American Academy of Neurology (AAN) practice parameters assign EEG a false-positive rate (FPR) of 3% with a CI of 0.9; making it the least predictive method to determine neurologic outcomes. Abend et al., pooled four existing studies on EEG in cardiac arrest (CA) patients who had undergone therapeutic hypothermia and found that 29% of these patients had acute electrographic non-convulsive status epilepticus (NCSE).5Conclusion: There is no good evidence from well-designed studies to support substantial accuracy of early prognostication ( < 72 hours post-arrest) in cardiac arrest survivors treated with therapeutic hypothermia.2,6 Given our lack of understanding of how therapeutic hypothermia improves outcomes, as well as its effects on emergence from the coma and its well-described effects in altering drug metabolism and clearance, it is prudent to be more conservative in approaching prognostication. Patients should be observed for a minimum of 72 hours post-arrest. However, 5-7 or more days of observation may be necessary to fully account for the effects of therapeutic hypothermia.
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DVT prophylaxis in critical care: role of NOACS
More LessThe incidence of deep vein thrombosis (DVT) in the critically ill ranges from 3.6% to 37%. Despite seemingly adequate prophylaxis the risk for DVT is still between 4 and 15%.
Currently the known risk factors can be divided into inherited and acquired. In addition, the underlying disease and comorbidities play a major role, e.g., history of DVT, malignancy, ongoing infectious disease, cardiovascular disease and pregnancy1.
DVT prevention is applied in various ways and timings. Principally, the choice is between mechanical, pharmacological and a combination of both.
Regarding the mechanical prophylaxis, recommendations point more to the use of intermittent pneumatic stockings (IPS), which are more effective with less side effects than simple stockings2. Whenever pharmacological treatment carries a relatively high risk (e.g., fresh bleeding, traumatic brain injury) mechanical prevention might be started. However, it is still under debate whether the combination of IPS with pharmacological prophylaxis is superior.
Like all anticoagulant therapy, the risk (and consequences) of DVT should be balanced against the risk of bleeding. A variety of scoring systems, like the Well's score, the Caprini score and the Has-Bled score exist to group the risks. In terms of risk assessment, bleeding after peripheral surgery might be less dangerous than after intracranial surgery.
In general, low molecular weight heparins (LMWH) are preferred above unfractionated heparin (UFH). One reason might be the risk of heparin induced thrombocytopenia (HIT), which is higher with UFH than with LMWH. On the other hand, UFH have a shorter half-life necessitating at least two daily injections, while the LMWH schemes apply a once daily injection3. However, the shorter half-life and the ease of reversal might be an argument for UFH use in patients at bleeding risk. In contrast, LMWH's carry a higher risk of bioaccumulation4,5. The route of application seems to be another point of concern. In the critically ill, peripheral organ perfusion might be disturbed by the disease or the therapy (i.e. vasoconstriction or edema).
It is still a debate if oral anticoagulants should be used in critical care. Mainly concerns are raised from pharmacological considerations. For instance, if enteral feeding is only possible via tubes, grinding of tablets will change the galenic of the drugs and their bioavailability. In addition, it is not clear whether orally applied drugs will be resorbed completely. Excretion of drugs might be altered due to impairment of kidney and/or liver function which could result in their accumulation.
Finally, changes in the coagulation system due to the underlying disease might occur unexpectedly and therefore unanticipated.
In concert with difficulties in laboratory measurement and reversal of the drug benefits of oral anticoagulants do not outweigh risks and disadvantages. Therefore, it seems not recommendable to start any kind of oral anticoagulation before the patient's condition is stable enough which is mostly the moment of discharge from the ICU.
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Rheumatology in ICU
By Tasleem RazaAutoimmune rheumatological disorders are rare but important to consider in Intensive Care Unit (ICU) patients. Overall prevalence of these disorders is approximately 3% in the general population. About 25% of patients presenting with these disorders to the emergency room (ER) require hospital admission and up to one third require ICU admission.1 Mortality is variable and reported to be around 20% in recent studies.2,3
The most common rheumatological diseases requiring ICU admission are systemic lupus erythematous (SLE), antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitides, rheumatoid arthritis, scleroderma, and dermatomyositis.1–3 The most common reasons for admission are infections and exacerbation of an underlying disease. The factors associated with mortality include Acute Physiology and Chronic Health Evaluation (APACHE) - II or Sequential Organ Failure Assessment (SOFA) score, vasopressors support, and prolonged hospital stay.2,3
In most patients with rheumatological disorders, the underlying disease is known at the time of admission. The diagnostic considerations in these patients include infections, underlying disease exacerbation, iatrogenic toxicity, or a rheumatologically unrelated disorder. The most difficult and challenging problem in these patients is differentiating between sepsis and exacerbation of an underlying disease, and laboratory markers may help in this differentiation. In SLE patients an ESR/CRP ratio >15 is suggestive of disease flare while < 2 is suggestive of infection. CD64, 2’5’-oligoadenylate synthetase (OAS) and soluble triggering receptor expressed on myeloid cell type 1 (sTREM1) are also promising biomarkers in differentiating infection and disease flare in SLE. A “bioscore” combining different biomarkers may be more useful than a single biomarker in differentiating disease flare versus infection.
Some medical conditions should always be on the radar of an ICU physician when patients present with multisystem disease with no clear underlying etiology. These include macrophage activation syndrome which may occur at any stage of rheumatic disease (onset, during active disease, during quiescent disease). A ferritin level of >10,000 microgram/L is pathognomonic, and >5,000 is highly suggestive of this diagnosis. Elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), high CRP with low ESR may also help with this diagnosis.4,5 In scleroderma, renal crisis should never be missed and initiation of angiotensin converting enzyme inhibitors (ACEI) should be prompt to avoid morbidity. In any patient with livedo reticularis, digital ischemia, splinter hemorrhages, ulceration and superficial gangrene of lower limbs with multi-organ failure and SIRS, catastrophic antiphospholipid (APL) syndrome should be suspected. Any patient on methotrexate (MTX) should be evaluated for pneumonitis and bone marrow toxicity related to MTX. ANCA-associated vasculitis should be considered in any patient with combined respiratory and renal failure.4,5 Bronchoscopy should be prompt in this situation to rule out diffuse alveolar hemorrhage.
In summary, rheumatological disorders are relevant considerations in any patient with single or multi-organ failure in ICU when the underlying etiology is not obvious. A routine immunological screening may be lifesaving in this setting and prompts further work-up and diagnosis. It is extremely important to involve a rheumatologist early in the management of any patient with known or suspected rheumatological disorder. Frequent collaborative discussions and meetings may go a long way to improve prognosis of these patients in the short and long term.
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Pediatric sepsis improvement pathway: Qatar experience
Authors: Ahmed Labib and Rasha AshourBackground: The World Health Organization acknowledges sepsis as a global priority. Healthcare providers and governments have a critical role to play.1 National sepsis programs have been established in Qatar and in many other countries.1,2 Here, we share our pediatric sepsis program development and success. Missing signs of early sepsis in children can result in delayed management, complications, and death. A standardized pediatric sepsis pathway based on creating a “THINK SEPSIS” culture incorporating an electronic early warning system and improving effective communication among healthcare providers using standardized tools can help early sepsis recognition, timely management and proper escalation, and ultimately improve patient outcomes.3–5Methods: Building on the structure of the adult sepsis program, the pediatric sepsis committee was established in 2017 and a National Pediatric Sepsis Program was created.
It is based on a multifaceted approach of education, governance, awareness campaigns, and utilization of an electronic medical record system. Simulation sessions of pediatric sepsis were delivered to fill knowledge gaps. To further pediatric sepsis care in Qatar the following steps were completed:
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• Established a pediatric sepsis clinical pathway and guideline to be followed in all clinical areas at all times whenever a child is suspected or confirmed to have sepsis, hence avoiding variation of practice and saving valuable time.
• Introduced sepsis watchers in the daily safety huddle to facilitate continuity of care and alert staff concerning deteriorating patients.
• Provided a standardized pediatric sepsis diagnostic kit with all required investigation equipment and IV access to all concerned units to minimise delays and standardize care (Figure 1).
• Unified the pediatric sepsis antibiotics kits in all units with a safe first dose preparation protocol based on the most recent antibiogram to ensure the delivery of the first dose within 60 minutes of pathway activation.
• Rolled out an e-learning module which is simple, interactive, and evidence-based for staff to be acquainted with the program and to increase awareness.
• Developed an electronic pediatric sepsis order set allowing clinicians to initiate all elements of the sepsis bundle within a few minutes, saving time and ensuring consistency and reliability (Figure 1).
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1. The proportion of clinical review, Rapid Response Team activation, and sepsis alerts that were appropriately escalated is 91%. This is an important achievement to ensure timely intervention thus saving lives (Figure 2A).
2. 81% of patients received IV antibiotics within 60 minutes of time zero. This is an essential element of sepsis care bundle (Figure 2B).
3. Pediatric sepsis golden-hour order set was initiated in 26% of cases (Figure 2C).
4. Achieved sepsis bundle compliance of 42%.
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Optimal fluid management in sepsis
More LessSepsis clinically manifests as life-threatening organ dysfunction due to a dysregulated host response to infection.1 Optimal fluid resuscitation is relevant for all sepsis patients, and perhaps it is most important for those with septic shock. Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greatest risk of mortality, and septic shock is clinically identified as sepsis patients with serum lactate level >2 mmol/L and who require vasopressor infusion to maintain a mean arterial pressure ≥ 65 mm Hg in the absence of hypovolemia. Sepsis is among the most common conditions in the intensive care unit (ICU), accounting for up to half of all hospital deaths and being the third leading cause of death overall in the United States.2
Sepsis and septic shock are medical emergencies for which treatment and resuscitation should begin immediately. The goals of fluid resuscitation for these patients are: a) to rapidly replace intravascular volume and restore tissue perfusion, and b) to minimize organ dysfunction through timely interventions that either halt or reverse the physiologic derangements. If hypoperfusion is present, at least 30 mL/kg of IV crystalloid fluid should be given rapidly, and additional fluids should be guided by frequent reassessment of hemodynamic status, preferably using dynamic indices to indicate the likelihood of a beneficial response to fluid administration. Fluid administration should be targeted to achieve a MAP of at least 65 mm Hg, and to normalize lactate in patients with elevated lactate due to hypoperfusion.3
Balanced crystalloids are the fluid of first choice for sepsis resuscitation based on ready availability and taking medication costs into account. Use of 0.9% saline compared to a balanced crystalloid, such as lactated Ringer's or PlasmaLyte, produces more kidney dysfunction and with a greater risk of dying.4 The individual side effect profiles may best differentiate the natural and synthetic colloids. Albumin may be considered for administration to sepsis patients with refractory shock or who have received substantial amounts of crystalloid fluids, but should not be administered to patients with severe traumatic brain injury.5 Hydroxyethyl starch (HES) products should not be administered to patients with sepsis because of increased risk of acute kidney injury and death. Gelatin solutions are not recommended in sepsis.
Norepinephrine is the vasopressor of first choice for patients with septic shock, and should be administered to achieve a mean arterial pressure of at least 65 mm Hg after excluding hypovolemia as a cause for hypotension. The selection of a second line vasopressor, such as vasopressin, dopamine, phenylephrine, epinephrine or angiotensin-2, depends on patient factors such as underlying cardiac dysfunction, presence of arrhythmias, and current response to vasoconstrictor or inotropic agents. Dopamine should not be used for renal perfusion or protection and it should be avoided in patients with tachyarrhythmias.
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Pharmacokinetic/pharmacodynamic variations during sepsis/septic shock
By Dana BakdachSepsis, a heterogeneous syndrome, is usually associated with uncontrolled body response to a systemic infection leading to dysregulated pro- and anti-inflammatory cascades.1 This, subsequently, leads to immune suppression, tissue damage, and organ failure. With time, the natural body compensation is lost and a state of shock, characterized by profound hypotension and abnormal cellular metabolism, ensues. Sepsis and septic shock are thus considered major challenges in critical care management due to the high rates of complications, including morbidity and mortality. Successful management of sepsis/septic shock necessitates implementation of urgent treatment measures targeting the underlying infection, as well as improving patient's hemodynamics.2 Treatment measures include administration of antimicrobials, vasoactive drugs, sedatives, analgesics, along with others with the aim of achieving effective, yet safe concentrations of different administered medications at the targeted site of action.3 However, this aim of efficient medication dosing attainment can be challenging in critically ill septic patients. The host response to sepsis is usually associated with tremendous changes of different physiological processes.3,4 Different studies have shown that such pathophysiological alterations were linked to dysregulations in both pharmacokinetic (PK) and pharmacodynamic (PD) properties of different administered medications and thus result in complicated drug dosing.3,4
Pharmacokinetics of a given therapy is usually linked to the administered dose and the corresponded changes of concentrations inside the body with time, whereas pharmacodynamics describes the resultant relation between the obtained drug concentration and its pharmacological effect. In-vivo efficacy of an administered medication is largely driven by its intrinsic PK and PD properties. Variations in PK/PD are not always universal or easily predictable, and different aspects can affect the overall discrepancies. Those aspects include disease, patient and drug related factors.5 For instance, the alterations of PK/PD properties seen with sepsis can be different from those seen with septic shock. A similar thing applies to the drug properties where the therapeutic concentrations of a lipophilic medication might be less prone to changes as compared to a hydrophilic therapy. Likewise, the co-existence of different conditions that influence overall medications' pharmacokinetics can complicate proper prediction of therapeutic concentrations. This is frequently encountered in critically ill patients presenting with sepsis/septic shock and requiring the use of renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO), plasmapheresis, or even all in certain individuals.
A deep understanding of various pathophysiologic changes seen in critically ill patients and their effects on the overall drug PK/PD is thus essential. This ensures that personalized dosing regimens are tailored to each patient to achieve an optimized therapy rather than using a “one size fits all” model of drug dosing. The implementation of personalized tailored therapy based on patient specific parameters, along with the utilization of therapeutic drug monitoring can successively give rise not only to improved clinical efficacy but also to decreased toxicity and antimicrobial resistance. Subsequently this would result in improved patient outcomes and survival.
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Beta-blockers in sepsis
More LessCatecholamines are an integral component of the host stress response and usually increase appropriately at times of need. Unfortunately, in severe and prolonged critical illness, they can contribute to significant harm with unwanted biological effects on cardiac function, inflammatory, immune, metabolic, and coagulation pathways1. A good example is Takotsubo (‘stress’) cardiomyopathy where heart failure ensues after an emotional stress resulting in extremely high levels of circulating catecholamines, considerably above that seen in a significant myocardial infarction2.
Unwittingly, we are likely contributing to catecholamine toxicity in our management of the critically ill septic patient through use of exogenous catecholamine therapies which carry the same detrimental effects as endogenous catecholamines1,3. Catecholamines are currently recommended first-line agents for septic shock, and are used in an attempt to overcome the vascular hyporeactivity and myocardial depression associated with sepsis. Use of higher doses of catecholamines is however associated with worse outcomes4. This is usually ascribed to the patient's underlying illness severity and an iatrogenic contribution is not considered – but perhaps should be.
Beta-blockers have multiple actions, on cardiac function and beyond. They reduce cardiac work through negative inotropic and chronotropic effects. Importantly, through slowing an excessive heart rate, both systolic and diastolic ventricular function are improved. They also act on adrenergic receptor responsiveness, enhancing the activity of catecholamines and allowing reductions in dose to achieve the same haemodynamic effect. Outside the heart, they improve vascular tone, enhance metabolic efficiency, and have anti-inflammatory effects and anti-thrombotic activity.
The first use of beta-blockade in sepsis goes back nearly 50 years with successful use in some patients in refractory shock. In the last decade an increasing number of observational studies and a few single-centre randomised controlled trials have shown both safety and improved outcomes5. These reflect findings in animal models of sepsis where various mechanisms were demonstrated including protective effects on the heart, anti-inflammatory actions and preservation of the gut barrier5.
Clearly, the patient needs to be adequately fluid-resuscitated and stabilised before commencing beta-blockers. Ideally, the use of a short-acting agent such as esmolol or landiolol allows easy titration, or cessation, of the infusion should hypotension or excess bradycardia occur with the unwanted effects wearing off within minutes. The largest study to date by Morelli et al., randomised 154 septic shock patients to receive either placebo or esmolol to reduce heart rate to 80-95 bpm. This was successfully achieved with no increase in complication rates compared to placebo. Importantly, there were also benefits in terms of earlier recovery of renal function, cessation of norepinephrine infusion, lower troponin levels (indicative of less cardiac damage), and improved survival rates. These encouraging findings need to be repeated in multicentre settings and two studies (one UK-based “STRESS-L”, one in 4 European countries) are currently ongoing.
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Debriefing in critical care
More LessDebriefing after critical events is a well-known practice in medicine, utilized in both simulated and real-life situations. In addition to reviewing the medical aspects of the care, debriefing allows for examination of team performance and human factors involved in the event. Various methods, locations, and time intervals can be utilized to debrief to meet the team's needs. Some proven methods of debriefing include plus-delta, directive feedback, the Socratic Method, and advocacy and inquiry.1 Each method has its benefits and limitations and can be applied during various segments of a debriefing to achieve the debriefer's goals. These goals usually include identifying and addressing knowledge gaps, uncovering participants' beliefs and thought processes, reflecting on the team's performance, and synthesizing the information to improve future performance.2 Debriefing should be a planned follow-up to every critical event. This standardizes the process and expectation for teams to share their experiences and work towards an improved performance. The debriefing environment should be a safe space for team members to express their emotions while sharing successes and challenges without fear of repercussion or blame. Allowing team members to share their decision-making process and knowledge level lets the debriefer tailor learning points to address appropriate deficits rather than assuming and targeting areas that may not need improvement. In addition, involving team members from all involved disciplines can enhance the outcomes of the debriefing. There is evidence that handoffs with more team members can improve efficiency, documentation, and future patient outcomes.3 The timing of these debriefs can be varied based on the clinical scenario and even the emotional state of the team members. Immediately debriefing after an event, also known as the “hot” debrief, allows most team members to participate and capitalizes on a clear memory of events to identify successes and opportunities for improvement. In addition to performance improvements, these sessions may help team members express their emotions and offer some coping skills to deal with unfortunate outcomes including the death of a patient. However, sometimes the debriefer may assess the emotional state of the team and deem it not appropriate to conduct the debriefing immediately after the event. In these settings a delayed debriefing session, or “warm” or “cold” debrief, may allow team members to process their emotions and reflect on the clinical event prior to coming together as a group to discuss their performance.
Despite the well described benefits of debriefing, there continues to remain a disconnect between knowing to conduct debriefs and their actual implementation. This can be due to various circumstances including, time pressures, patient care, or limited training in how to debrief a team. These failures to debrief can lead to communication breakdowns within the team.4 The absence of a debriefing can also lead to improper or inadequate documentation, which can result in clinical error and increased litigation.5 Organizations such as the Agency for Healthcare Research and Quality advocate for clinical event debriefing; this attention and effort on research and training can hopefully increase the frequency of and comfort with clinical event debriefing.
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Why don't we mobilize our ICU patients early?
More LessThere are several questions that need answering regarding mobilization of Intensive Care Unit (ICU) patients. How do we mobilize ICU patients? Is there an internationally agreed definition? Is there an internationally agreed prescription/program for mobilizing the patients? What is considered early? Why should we mobilize our patients, and lastly, why don't we?
Mobilization of ICU patients takes many different forms and views. It includes bed activities such as range of motion, turning, transferring, self-care, breathing exercises, sitting at the edge of the bed, and even stationary cycling. There are also several out of the bed activities such as sitting in a chair, standing, and walking. Although several units have their own protocols, a literature review reveals that definitions are either too broad or too narrow, subsequently challenging to transfer these results.1
Some trials have started mobilizing patients from as early as the first day, while other trials have waited 48 hrs, 5 days, and even longer before mobilization was started. Most trials which have managed to deliver very early mobilisation have found improved outcomes up to hospital discharge, while trials which intervened later mostly found no significant effect.2 The absence of a definition for early, very early, and late initiation of mobilization makes comparing studies very difficult.
Muscle weakness that develops during the ICU stay is called ICU-acquired weakness (ICU-AW). It manifests as generalized muscle weakness that is often severe. It develops in ICU patients who receive mechanical ventilation for 24 hours or more and is associated independently with prolongation of the duration of mechanical ventilation and ICU and hospital stay. ICU-AW is associated with increased mortality in the first year following ICU discharge. Mobilizing patients at an early time point decreases invasive mechanical ventilation (MV) duration, delirium, hospital length of stay, and reduced healthcare costs.3,4
Reported reasons for not mobilizing patients vary widely and include mechanical ventilation, catecholamine infusion, impaired consciousness, poor functional status, safety considerations, limited staff capacities, or lack of protocols. Absolute contraindications can include acute myocardial infarction, active bleeding, increased intracranial pressure with major instability, unstable pelvic fractures, therapy withdrawal, and lastly patients’ refusal.4
Recommendations on safety criteria for early mobilization mention that vasopressor use, endotracheal intubation, renal replacement therapy, or even life support devices like ECMO should not be considered as contraindications for active mobilization. Only one study has explored the safety of very early mobilization in critically ill patients on multiple support systems.4
Multiple QI projects have successfully implemented and sustained early mobilization projects within the ICU setting and all identified strong leadership for early mobilization. This along with the multidisciplinary team approach ensured success and sustainability of mobilizing ICU patients.5
In conclusion, there is a lack of internationally agreed protocols or guidelines on when and how we should mobilise our patients. There are also several obstacles facing us even once achieving consensus in that. The good thing is that we are clear on why we should mobilise our patients and hopefully this will drive further research to standardize the above unanswered questions.
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What is the future of ICUs?
More LessICUs in the future will comprise a larger percentage of hospital beds as care of less seriously ill patients shifts to home and other environments. ICUs will need to adapt to increased demand for services and concomitant economic pressures with efficiency and innovation. The future ICU will see changes in form, function, personnel and patients.
The type of patients in ICUs and their medical conditions will be different. Prevention, early detection, and timely treatment of conditions such as infection and respiratory failure should decrease the need for many ICU admissions. Patients needing ICU care will have multiple complex problems that shift the epidemiology of critical care. This shift in patient populations will not change the need for compassionate and empathetic care.
Precision medicine for patient care is the goal of the future ICU—tailoring therapy for conditions based on individual characteristics, risk profile or genetic markers1. Protocols and guidelines will require the ability to adapt to defined patient groups.
The physical ICU environment of the future must promote a healing environment for patients, families, visitors and ICU staff2. Optimal design should reduce noise, maximize work efficiency, minimize potential for errors, decrease infection risk, reduce stress and provide comfort for families and visitors. The environment will address sound, light, temperature, smell, art and entertainment needs. The ICU of the future must be a flexible environment with built-in adaptability for technological advances. Cohorting of critically ill patients in a defined ICU area will continue for efficiency but the flexibility to deliver critical care outside the physical ICU must also be provided. Patient-centered care will continue to drive services in the future.
The ICU of the future continues to require a highly trained collaborative team of professionals but roles and responsibilities as well as composition of the team will change. Intensivists will still oversee these teams but advanced practice providers and non-intensivist physicians may play greater roles in direct patient care. Greater emphasis will be placed on preventing burn out in team members through use of smart technology, optimum work environment and professional support.
Technology will be the most constantly changing variable in future ICUs that will affect the environment, patients, and staff. Sophisticated informatics will interface all hospital systems with the ICU and advance individualized care3. These systems must have characteristics of association, interoperability, integration, security, safety, and real-time synchronization4. Artificial intelligence and learning will address the challenges of information overload and integration of data to enable optimum decision making. Electronic “sniffers” will detect and interpret changes in patients’ clinical status and send alerts to clinicians or potentially initiate interventions. In addition, alarm systems will screen out irrelevant signals and decrease the danger of “alarm fatigue” but at the same time provide early alerts to safety issues and provide suggested actions. An outgrowth of advances in information technology will be the use of “big data” to optimize immediate patient care as well as advance research in the ICU5.
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Bridging the gap: Improving patient safety through targeted in-situ simulation training in a paediatric intensive care unit and Learning from Excellence (LfE)
Authors: Prabhakar Nayak, Nikki Kidd, Bianca Osborne-Ricketts, Jeff Martin, Yvonne Heward and Adrian PlunkettBackground: Improving patient safety and reducing risk is important to a Paediatric Intensive Care Unit (PICU). Simulation-based education has generally focused on the management of clinical diagnoses, whereas the Quality and Safety Team has traditionally focused on collecting and analysing data about adverse events. There is a need to bridge the gap between the two streams - lessons learnt from adverse incidents and their impartation to staff in a targeted format during in-situ simulation training.
Methods: Birmingham Children's Hospital PICU is a 31-bedded tertiary/quaternary unit with approximately 1500 admissions per year in the UK. All adverse incidents are collated (online IR1 with specific forms for incidents involving medications, accidental extubations, buzzer pulls, and extravasations) and analysed by the PICU Safety Group and trends are monitored. The PICU Simulation Team delivers in-situ simulation training for the multidisciplinary PICU staff weekly using interactive, computer-controlled manikins. Each training scenario and debriefing lasts 1 hour. A core team of multidisciplinary simulation facilitators runs the simulation training and the AI (advocacy-inquiry) debriefing model1 is used for conducting the debriefings. The ‘Simulation Group’ (efferent) and the ‘Risk Group’ (afferent) regularly discuss the priorities for the unit and the lessons learnt based on actual events or near-misses in the unit. It then implements the action points during targeted scenario training sessions. This may be the utilisation of a care bundle or activation of a ‘clinical pathway’. Any practical problem with implementation of these policies is fed back to the Risk Group to close the loop. A concept of ‘Learning from Excellence’ (LfE) has been introduced successfully and both ‘adverse incidents’ and LfE are used together as approaches to improve patient safety in the unit.
Observation/Evaluation: Various simulation scenarios have been run since the start of the project. Examples include accidental extubations, delay in sepsis recognition and antibiotics prescription, ischaemic limb injury due to the indwelling arterial line, emergency chest reopening in post-operative cardiac surgical patients, child protection and safeguarding2. The learning gained during each debriefing is generalised to all the participants of the simulation session3 and then subsequently the salient points are shared by email with the entire unit. All staff members have to undergo simulation training. Scenarios are re-run back to back if the team does not achieve the expected outcomes. The anonymous feedback forms completed by the participants of the scenarios have shown they value this targeted training and that it has helped them implement good practice. Anecdotaly, the trend of ‘incident severity’ is believed to have been on the decline over a 7-year period in our PICU but long term monitoring will continue to identify any re-emerging or fresh trends.
Conclusion: ‘Targeted’ simulation-based training is an important approach to enhance the safety culture in PICU. PICU Safety and Simulation Groups should develop a symbiotic relationship for this to succeed. Learning from Excellence can be effectively utilised to embed good practice in a clinical area.
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Social media and critical care
By Mamoon YusafSocial media has transformed the way we communicate with each other in the last decade or so. Out of 4 billion internet users, more than 3 billion are on social media. The medical community has also been transformed in terms of how we approach this vast medium of information. Microblogging sites like Twitter are beneficial in the way we share and disseminate professional knowledge. The critical care community has recently gained a lot of pace on the social media platform and are showing their presence in numbers.1 Although use of social media in critical care has great potential to benefit its users, it comes with its own challenges. This includes inaccurate information and slow adaptation. So the question arises: How can the critical care community make the best use of social media resources while ensuring the right knowledge is shared and practiced, and patient confidentiality is always respected?
Twitter has been used as a medium to not only spread information but also as a platform to teach critical care physicians and nurses. There are elements which affect the usability, efficiency, effectiveness, and widespread acceptance of Twitter as a teaching aid.2 FOAM, free open access medical education, is an online movement taking place across social media, blogs, and podcasts that is challenging traditional methods of medical education.3 FOAM provides a free platform for learners to not only receive information but also share it with other users. It gives the learner a chance to tailor their resources according to their individual needs. In addition, learners can reach out for assistance from the source much more easily as compared to traditional ways. But concern has been raised on how to best approach these resources as they do not undergo vigorous checks like peer reviewed articles. Check and balance of the validity of the provided information is often left up to the learners discretion. It can leave educational gaps at times and may not be applicable worldwide. Similarly, declaration of conflict of interest is not mandatory on these platforms hence it is often impossible to identify commercial bias.
It can be quite difficult to keep track of all the continuing professional development hours spent on social media but new applications are being developed, which can help. While on social media, all the norms and etiquette of healthcare professionalism should be maintained such as patient confidentiality and appropriate interprofessional relationships. There are evolving tools to evaluate the quality of various resources like SMi (Social Media Index)4 and HONcode (Health on the Net Code of Conduct).5
Social media, when used correctly, can be effective for self-directed learning, holding discussions with other critical care and healthcare professionals while reflecting on newly-acquired knowledge. Although the information must be used with due care, as the peer review is mostly inexistent in social media as people can post what they want, it is one of the most exciting and evolving areas in critical care practice.
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How to do clinical trials in the ICU
More LessSite-initiated clinical trials are challenging, particularly with vulnerable populations like ICU patients. But they can be useful if you can answer “Yes” to these questions: (1) Could the answer change practice? (2) Does my ICU see enough of these patients to answer the question? (3) Can I treat both the investigational and control group patients in a fair manner? Other approaches to ICU clinical research, such as joining another multicenter clinical trial and observational (prospective or retrospective) studies whose answers have explanatory power may also be valuable.
Regarding changing practice: The trial's answer should be important enough that any intensivist treating such a patient would care about it. Examples of questions that probably aren't important enough are: (1) Is there a difference in ARDS outcome if the tidal volume is 4, 6, or 8 mL/kg?, (2) Is knee-high pneumatic compression inferior to thigh-high pneumatic compression for thromboembolism prophylaxis in anticoagulant-contraindicated patients?, and (3) Do piperacillin-tazobactam and cefepime have equivalent efficacy for empiric coverage of hospital-acquired infections? The first question probably has a patient-specific, non-generalizable answer; the second, with small “dose” differences has high risk of being a negative study; the third answer likely depends on local organisms, and equivalence studies require very large patient numbers.
Studies whose answers probably could change practice include: (1) Does adding Extracorporeal CO2 Removal (ECCO2R) to intubated ventilation in combined respiratory and metabolic acidosis improve survival/shorten ventilator time?, and (2) Does extracorporeal CPR (ECPR) for witnessed out-of-hospital cardiac arrest with a shockable rhythm save lives? Regarding the ECCO2R proposal, current practice involves hyperventilating high-dead-space patients, pressors, bicarbonate infusion, maybe dialysis, and outcomes are poor. ECCO2R can reduce ventilatory and alkalinizing/dialysis requirements1. Regarding the ECPR proposal, current survival rates reported after 60 min of CPR without ECPR for possibly salvageable patients are 9%; with ECPR, 22%. Moreover, there are no clinical trials published2.
The second criterion is important because if your site doesn't see enough patients, coordination with multiple centers and delay can imperil completion. Estimating sample size early for feasibility is important. For the ECCO2R proposal, an estimate for 30-day survival of such patients is 25%. To double survival to 50%, 2-sided p = 0.05, with 80% power, sample size is 65/group, 130 patients altogether. For the ECPR proposal, an estimate without ECPR is 5% survival after an hour of CPR. To raise survival to 25%, 2-sided p = 0.05, with 80% power, sample size is 58/group, 116 patients. These numbers may be practically achieved in some centers after 2-3 years, when the answers will still be pertinent.
The third criterion addresses whether the question is practical: Can a protocol fair to patients be devised and executed? For both ECCO2R and ECPR proposals, the protocols must (1) Establish criteria to assure no prolongation of life just to favor one unblinded group or another, and (2) Establish a process to assure uniform patient entrance and procedures among participating physicians and centers. Careful thought and collegial consultation at the start of study planning is important for helping ICU patients with your clinical research. Preparing the final study report similarly requires close attention and consultation3.
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Burnout signals are alarming worldwide: the active role of leadership
Authors: Amr S Omar, Yasser Shouman and Suraj SudarsananIntroduction: The burnout phenomenon first came to clinical science 50 years ago. It is exponentially rising worldwide which prompted its discoverers to develop the most popular tool for its assessment, known as the Maslach burnout inventory (MBI)1. Common symptoms of burnout include depression, irritability, and insomnia. It is known to hit professional areas where higher levels of stress are common. Intensive care unit (ICU) practitioners are particularly vulnerable to this condition. Bienvenu reported that up to 45% of ICU staff experienced burnout at a certain time in their career. The contributing factors include: age, gender, work schedule, involvement in decisions of withdrawing life support, policy of visiting hours, work quality, and care of dying patients. It is described as a growing crisis and is currently gaining a lot of interest aimed at addressing the issue and its consequences2. We hypothesize that positive leadership with empowerment of staff may have an impact on burnout. Our objectives are to explore the prevalence of burnout in this area, to find the contributing factors, and determine the impact of the role of empowerment and leadership on burnout. Method: We conducted a cross-sectional descriptive study using a combined methodological quantitative and qualitative approach involving a convenience sample of 200 healthcare practitioners within surgical and medical ICUs of Hamad Medical Corporation (HMC), Qatar. We used two main instruments to develop an online questionnaire:
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– The MBI-human service survey (MBI-HSS)1 which is a standardized instrument to measure burnout. It utilizes 9 items related to emotional exhaustion and it is most frequently used in healthcare research. A score of 27 and more signals a high burnout level.
– The Leadership scale, which assesses staff discernment of managers’ leadership attitude3. It is based on a 7-point Likert scale 11-item questionnaire that considers resolving conflicts with others, autonomy in decision-making, and staff involvement in development.
Conclusions: Everyone is at risk of burnout in the ICU setting. Implementing the empowerment hypothesis among the ICUs in Qatar could enhance the managerial preferences in the hospitals dealing with a wide spectrum of healthcare practitioners.
Empowerment is symbolized by energizing the practitioners5 and as the awareness of burnout is increasing, proper interventions should be directed at adequate orientation, early recognition, and dealing with the predisposing factors to prevent future occurrences. The findings of this study could widen the scope of practitioners who could be involved through education in diagnosing and managing burnout.
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Weird and wonderful ICU cases: Unusual causes of shock
More LessDuring their practice, intensivists are ought to face challenging cases that are rare. Intensivists need to be aware of the rare causes of shock beyond common presentations. In each category of shock, there are rare causes that require prompt identification and management. Certain clues in the patient's presentation might point to those rare causes.
Classically shock is classified into: distributive, hypovolemic, cardiogenic, and obstructive. In this era of bedside point-of-care ultrasound, intensivists are able to promptly identify the cause of shock and institute a resuscitation plan. However, there are cases when the diagnosis is still obscure and the cause of shock is not easily identified. For example, in a study of patients admitted with presumed septic shock, 7.4% had no identified cause of shock and 11% had sepsis mimickers.1
Hypovolemic shock occurs secondary to a reduction in the effective circulating volume secondary to fluid loss or third spacing. A rare cause of hypovolemic shock is idiopathic capillary leak syndrome (Clarkson Syndrome).2 The syndrome is characterized by recurrent episodes of rapidly progressive generalized edema, shock, renal failure and high hematocrit. The episode usually resolves in 3-7 days where the capillary leak resolves and a phase of pulmonary edema occurs. Several treatment options such as intravenous immunoglobulin (IVIG) and aminophylline were used in case reports.3
Vasodilatory shock occurs secondary to peripheral vasodilation and decrease in blood flow. It occurs as part of the systemic inflammatory response syndrome for which sepsis, acute pancreatitis, acute liver failure, and major trauma are common causes. Rare causes that need to be considered include: hemophagocytic lymphohistiocytosis (HLH), systemic mastocytosis, and toxic shock syndrome.
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by macrophage activation and engulfment of hemopoetic cells which leads to pancytopenia. It is also characterized by cytokines storm that lead to a vasodilatory shock, multi-organ failure, and acute respiratory distress syndrome (ARDS). The most common triggers are infection, malignancy, and autoimmune diseases. Pointers to this diagnosis in the intensive care unit include: pancytopenias, hypofibrinogenemia, high triglycerides, and high ferritin. Treatment necessitates treating the underlying cause as well as using immune modifying therapies.4
Systemic mastocytosis is a rare cause of recurrent anaphylaxis shock. It results from the accumulation of mast cells in tissues and can present with anaphylaxis and vascular collapse. An important clue to the diagnosis is the presence of urticarial pigmentosa and the absence of an allergen history.5
Toxic shock syndrome is a unique cause of sepsis. It is caused by a pre-formed toxin produced by Staphylococcus aureus and Streptococcus pyrogenes. The clue to the diagnosis include the rapid onset after the precipitating factor, erythroderma, and skin desquamation. Treatment includes IVIG and Clindamycin.6
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Factors contributing to patients’ presentation to the emergency department of an academic hospital in Oman after leaving other hospitals against medical advice
More LessBackground: One of the reasons to leave against medical advice (LAMA) from a hospital is to seek treatment in another hospital1. Those patients are at high risk of readmission and mortality compared to patients with planned discharge2. The aim of this study was to identify the factors for patients' presentations to an academic tertiary hospital Emergency Department (ED) specifically after LAMA from another hospital and to investigate the outcomes of these presentations. Methods: We conducted a prospective cross-sectional study. We included all patients who presented to Sultan Qaboos University Hospital (SQUH) ED after LAMA from other hospitals in Oman during the six-month study period. We excluded patients who died during hospitalization, those who refused to give consent, and those who were identified only after their ED visits' by reviewing the ED medical records' and were difficult to be contacted. We asked the participants to fill a paper-based questionnaire to investigate the factors of their presentations to SQUH ED. We designed the questionnaire by reviewing the literature on second opinion, patient's satisfaction, and LAMA3–5. The questionnaire underwent a content validation by two experts. We investigated the outcomes of the presentations by reviewing the patients' medical charts. We used descriptive statistics to analyse the data. Results: A total of 112 patients presented to SQUH ED after LAMA from other hospitals. 94 of them participated, while 18 patients were excluded. There was equal male to female distribution among the participants and their mean age was 36.8 years (SD = 26.483). Figure 1 illustrates the previous hospitals where patients LAMA. The majority of patients (66.0%) were LAMA from governorate hospitals. Table 1 presents the factors of presentation to SQUH ED. The most common factor to present to SQUH ED (94.7%) was to get the quality of care delivered in SQUH. Out of 94 patients, 70 (74.5%) were admitted to SQUH. More than one-third of the admitted patients (35.7%) required management in critical care units. Conclusion: This study provides the factors that lead LAMA patients to choose an academic tertiary hospital for their second presentation. Identifying these factors can help the decision makers in the healthcare system in Oman to increase the quality of services in other healthcare facilities. Providing more healthcare facilities with diagnostic modalities like Magnetic Resonance Imaging (MRI) and in some places even Computed Tomography (CT) imaging may help decrease the incidence of LAMA. Also considering the addition of diagnostic and therapeutic units (for example: endoscopic suites and angiography suites) may allow for better health services in these hospitals and therefore minimize the occurrence of LAMA. Furthermore, allowing for and addressing the need for second opinion in some patients and organizing for that formally between different specialties in these hospitals may improve the patient satisfaction and therefore reduce the incidence of LAMA. Ultimately all the previously mentioned interventions can minimize the morbidity and mortality associated with LAMA. The study can also act as a pilot for larger multicentered studies.
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Nutritional management of critically ill patients: outcomes associated with the implementation of a clinical dietetic service within a high-volume intensive care unit
More LessBackground: The provision of nutritional support among critically ill patients is complex and multifactorial.1 There is a gap in the literature around the optimal amount of energy and protein critically ill patients require.2 There has been a direct association with malnutrition and morbidity and mortality among critically ill patients.3,4 The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients.3 Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements.4 Furthermore, skeletal muscle activity is impacted from heavy sedation and the catabolic depletion of protein reserve must be prioritized in terms of nutritional management.5
Al-Adan Hospital in Kuwait caters for a population of 1.2 million, accounting for one third of the Kuwait's population. Clinical dietetics in the intensive care unit (ICU) at Al-Adan Hospital is an integral part of the multidisciplinary team and is deeply imbedded in the overall service. The dietetic model of care is proactive in nature and focuses on individualized patient care upon admission. Providing optimal nutritional support for critically ill patients extends beyond selecting the most appropriate formula and calculating caloric requirements. There has been a shift in the goals of care from “supportive nutrition” to “therapeutic nutrition”.5 The main objective of the dietetic service is to meet energy targets, preserve lean body mass, manage metabolic complications, and maintain patient immune function. Aim: This study will present recommendations for clinical practice and discuss outcomes associated with meeting nutritional targets. Methods: It is based on a literature review of existing guidelines, randomized controlled trials, and various meta-analyses examining the data available around nutrition in critically ill patients. Additionally, a description of a nutrition-focused model of care along with a retrospective analysis of routine data at Al-Adan Hospital ICU will be presented. Results: It is challenging to predict energy expenditure and energy requirements among critically ill patients. The current golden standard of care is indirect calorimetry however, its application among patients with altered gas exchange is debatable. Multiple studies have shown that there is a high rate of unintentional underfeeding among ICU patients due to feeding interruptions during procedures. In reviewing outcomes of 300 patients at Al-Adan Hospital, meeting the nutritional needs of patients throughout their ICU admission has shown to reduce the risk of infection and overall mortality (p ≤ 0.05) (See Table 1). Additionally, an association was observed between feeding intolerance and length of stay (p = 0.031). Conclusion: Observational data has demonstrated a positive association between meeting protein needs and survival. Applying a nutrition focused model of care within the ICU has clearly impacted on patient outcomes. Further research in the form of prospective randomized controlled trials exploring the optimal dose and time of nutritional therapy is necessary to examine nutritional needs of critical care patients.
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Hyponatremia induced compartment syndrome of all extremities: Case report and review
Authors: Nissar Sheikh, Gulzar Hussain, Arshad Chanda and Shakeel RaizBackground: Compartment syndrome is a well-recognised complication from trauma, burns, orthopaedic, vascular, or other surgery of the limbs. Hyponatremia related rhabdomyolysis leading to compartment syndrome of all four extremities with renal and hepatic impairment is rare.1,2,3 Although the rhabdomyolysis can occur without hyponatremia. Young men have the highest incidence of compartment syndrome, particularly after long-bone extremity fractures and strenuous exercise.4,5 We present a case of compartment syndrome of all four extremities following a brief episode of recreational jogging. Case: A 39-year-old Indian male, known hypertensive on nifidipine and indapamide was presented to the emergency department with generalized weakness, lower leg pain and cramps for 3 days. He had jogged for 2 km in warm temperatures. His symptoms worsened and he was unable to walk. Other complaints were headache, pain in both arms, and passing dark coloured urine for two days. Both his calf muscles were tender, tense to feel, and painful on flexion and extension. Dorsalis pedis pulses were weak but palpable bilaterally. Capillary refill was less than three seconds and sensation were intact in both lower limbs. Oxygen saturation of toes on both feet was 99%. Other body systems were unremarkable. His respiratory rate was 20 min− 1, blood pressure 210/110 mmHg, temperature 36.6°C, oxygen saturation (SpO2) 99%. Initial biochemistry results were serum creatinine 142 umol.l− 1, myoglobin 5791 ng.ml− 1, creatinine phosphokinase 19032 U.l− 1, sodium: 124 mmol.l− 1, aspartate aminotransferase (AST) 167 U.l− 1, and alanine aminotransferase (ALT) 49 U.l− 1 (Table 1). Doppler ultrasound of leg vessels showed no evidence of deep venous thrombosis, echogenicity of the muscles in the thigh and lower leg appeared within normal limits. Rhabdomyolysis was diagnosed and rehydration begun with Hartman's solution 1000 ml followed by 125 ml.h− 1. The patient was admitted to the ward for continued hydration and analgesia to treat the pain. His leg pain worsened overnight despite intravenous analgesia. His pulse in both feet became feeble and renal and hepatic function worsened. Compartment syndrome was suspected and orthopaedic surgery was consulted. He had an emergency fasciotomy of all compartments and in all four limbs. Post-procedure pulse oximetry of digits and toes had a 99% saturation, but peripheral pulses remained weak. He was able to move fingers of both hands, but had no movement of his ankles and toes. The patient was transferred to the intensive care unit (ICU) for further management. His maintenance intravenous fluid was changed to 0.9% sodium chloride due to persistent hyponatremia. His wounds were re-explored and debrided on the fifth post-operative day. Wounds culture were growing pseudomonas aeruginosa that was treated with Meropenam according to the sensitivity. Six sittings of wound debridement and irrigation were performed. Over two weeks his renal function, liver function, and serum sodium concentration normalised (Table 1) without requiring renal replacement therapy. He was transferred to the ward on day 16 and discharged home to be followed in outpatient clinic. Conclusion: Physical exercise in the presence of hyponatremia can cause rhabdomyolysis and compartment syndrome of all extremities leading to multi-organ failure.
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Analgesic sparing effects of Dexmedetomidine in surgical intensive care patients
Authors: Nissar Sheikh, Arshad Chanda, Saher Thaseen, Zia Mahmood, Adel Ganaw and Nabil ShallikBackground: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm.
Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertension were comparable to that mentioned in the literature. There was a significant analgesia sparing effect of dexmedetomidine. We continued Dex in the post-extubation period and the effective dose used was 0.2 mcg/kg/hour. There was no significant difference in occurrence of adverse effects with lower and higher range of Dex. The patients on a higher dose of Dex needed more rescue traditional sedation.
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A rare case of propofol related infusion syndrome in a neurosurgical patient
Authors: Ranjan M. Mathias, Nissar Shaikh, Arshad Chanda, Qazi Zeeshan and Shakhsanam MirishovaBackground: For the last three decades propofol has been used in anaesthesia and as a sedation technique. Several reports have warned about its use in higher doses for prolonged durations as it can have severe side effects such as propofol related infusion syndrome (PRIS), which can be fatal.1,2,3 PRIS is a rare and complex clinical condition characterized by severe metabolic acidosis, rhabdomyolysis, cardiac, liver and kidney dysfunction, and lipidemia. In its advanced stage PRIS can lead to severe refractory bradycardia and asystole.4,5
Propofol and remifentanil total intravenous anaesthesia (TIVA) is a popular anaesthesia technique. The target controlled infusion (TCI) gives predicted and controlled drug concentration and has added to the increased use of TIVA. Not much literature is available about the use of propofol and remifentanil TIVA and occurrence of PRIS. We report a case of PRIS in a neurosurgical patient with history of dyslipidemia. Case presentation: A 46-year old man weighing 68 kg, with a known case of hyperlipidemia, presented with decreased hearing on the left side, headache, and perioral numbness. Computerized tomography (CT) of the head showed left cerebropontine angle cystic lesion. His home medications were oral sodium chloride 1200 mg three times daily and pravastatin 20 mg once daily. He was electively scheduled for surgery under general anaesthesia, which lasted for seven hours. He received a TCI with propofol and remifentanil. He remained hemodynamically stable throughout the procedure.
Over 7 hours the patient received a total of 3332 mg of 1% propofol, remifentanil TCI 3–4 mcg/ml, ephedrine 18 mg, mannitol 20%–250 ml, pancuronium 16 mg, vecuronium 25 mg, cefazoline 2 g, dexamethasone 16 mg, neostigmine 5 mg, glycopyrolate 1 mg, and labetalol 25 mg. He received 2 liters of crystalloid and one liter of colloid during the surgery. Intra-operative blood sugar remained around 6–7 mmol/L and his central venous pressure was maintained between 8–11 mmHg.
His first arterial blood gas showed increasing lactate and metabolic acidosis after two hours of anaesthesia and it continued to rise till the end of surgery. He was extubated and shifted to the surgical intensive care unit (SICU) with a Glasgow Coma Score of 15, spontaneously breathing and with stable hemodynamics. The serum lactate continued to rise in SICU for the first 12 hours and then slowly started to decline (Figure 1). A graph of the trends of carbon dioxide and serum bicarbonate levels is shown in Figure 2. The triglycerides level reached 11.46 (Figure 3), creatine kinase 1852 U/L and myoglobin 474 ng/ml which showed decline within the next 24 hours.
He remained hemodynamically stable with adequate urine output. On day one we resumed atorvastatin 20 mg, labetalol prn, bicarbonate infusion. After 24 hours, his lactate levels were normalized and acidosis resolved. The patient was discharged without any complications.
Conclusion: Propofol TIVA with TCI is a common anesthesia practice. In a known dyslipidemic patient it will increase the risk for PRIS. In our patient, other risk factors for development of PRIS were higher dose, neurosurgical procedure, and extended duration of propofol infusion. The authors believe it is the first case of PRIS in a dyslipidemic patient undergoing neurosurgery with TIVA.
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Safety of prone positioning in critically ill patients
Background: During the past two years, 5% of patients admitted to the Medical Intensive Care Unit (MICU) of Hamad General Hospital (HGH) had severe acute respiratory distress syndrome (ARDS) with a PaO2/FiO2 ratio less than 100 mmHg. The risks associated with this condition include ventilator associated lung injury, over distension of lungs, and poor gas exchange which results in increased morbidity and mortality. With quality improvement initiatives like prone positioning, the mortality and morbidity associated with severe acute respiratory syndrome1 can be reduced by improving hypoxemia2 with a significant enhancement in PaO2/FiO2 ratios while reducing injurious ventilation. Also, prone positioning can help prevent invasive interventions such as placing patients on extracorporeal membrane oxygenation (ECMO) therapy.3Methods: We evaluated the safety of prone positioning for improving hypoxemia in critically ill patients with PaO2/FiO2 ratio < 100 mmHg to PaO2/FiO2 ratio < 200 mmHg from 1st January 2017 to 31st December 2018, without major complications. Data collected included the PaO2/FiO2 ratios based on arterial blood gases of mechanically ventilated patients before and after prone positioning.
We were able to facilitate prone positioning in 72 out of 110 patients with severe ARDS having a total average PaO2/FiO2 ratio of 84.4 ± 30 mmHg. The patients were proned for a maximum of 16 hours in each session where up to three sessions were incorporated. No major complications were encountered during the proning sessions. This was thought to be accomplished through the coordination of a dedicated multidisciplinary team, education and simulation classes for physicians, nurses, and respiratory therapists, following appropriate inclusion and exclusion criteria for prone positioning, and implementing quality measures through Plan-Do-Study-Act (PDSA) cycles as represented in Figure 1. Results: The total average PaO2/FiO2 ratio before proning for 65% of patients (n = 72) with severe acute respiratory distress syndrome4 was 84.4 ± 30 mmHg and after one hour of 16 hours proning, it improved to 180.3 ± 78 mmHg. The remaining 35% of patients either had traumatic fractures, unstable spinal injury, severe hemodynamic instability, or morbid obesity together with ARDS which made them unfavorable for prone positioning. Out of those who were proned, 11 (12.5%) patients did not have improvement in oxygenation after proning due to non-recruitable lungs and were put on ECMO. The PaO2/FiO2 ratios before and after one hour of implementing the prone position technique in each quarter of 2017 and 2018 are represented in Figure 2. Conclusion: In patients with severe ARDS, prone positioning proves to be a safe practice and leads to improvement in hypoxemia without major complications. Our future prospects with respect to prone positioning include the following:
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• Sustaining and standardizing the accomplished work of data collection.
• Implementing the prone positioning technique across other critical care units of Hamad Medical Corporation.
• Keeping a record of minor complications associated with prone positioning and resolving them in further sessions.
• Documenting cases with contraindications to prone positioning.
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