Neuro Resus: Recent Episodes
Oliver Flower
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
This presentation was delivered by Catherine Bell at CODA2022. Want more content about EVD? Visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients.
This presentation was delivered by Rob Loch MacDonald at CODA2022. Want more content about aSAH? Visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Lizzy suffered a substantial aneurysmal subarachnoid haemorrhage that left her critically unwell, requiring a long stay in intensive care recovering from the consequences and complications of this devastating form of stroke. Now a couple of years after her haemorrhage, Lizzy has come so far. She and her husband Gordon describe their experiences, right from the day it all began and through those tumultuous first few weeks, to where she is today. This open and honest account gives us all invaluable insight into what it’s like to go through the subarachnoid haemorrhage journey from a patient and family’s perspective, hopefully helping us empathise more and deliver better patient-centred care.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
This presentation was delivered by Andrew Udy at CODA2022. Want more content about The Bonanza Trial? Visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last 20 years, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, partially due to the favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
In this talk Toby Jeffcote initially takes us through all the sedatives currently used in brain injury and the evidence to support their use. He then covers the history of ketamine use and the background to new research in use as a therapeutic agent.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
This presentation was delivered by Toby Jeffcote at CODA2022. Want more content about CSD? Visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Andrew Chow vs Andrew Udy
This debate was set up to discuss the issues with categorising traumatic brain injury (TBI). The current system using GCS to divide patients into mild, moderate and severe has been criticised in recent times, with calls for a more nuanced approach. The debate was a just bit of fun but does highlight the key issues. Chowie didn’t get to choose which side to argue for :)
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for TBI works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations.
Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes the argument that biomarkers may better categorise the diffuse entity we call TBI.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI).
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Tania Farrar is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Stuart Browne is a Neuro Rehab specialist from Sydney. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
To express your interest in attending the 2024 Neuroresus live course, click here.
Shree Basu is a Paediatric Intensivist in Sydney. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
The blood pressure targets in ICU are discussed; while there isn’t strong evidence to support these targets, it does make sense and is a separate hot topic in adult strokes, especially post ECR!
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference.
Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways.
Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions.
Hypertensive therapy is relatively safe and easy to implement but not without risk.
In this podcast, Tessa Garside discusses the pros and cons, how this is managed practically and what the future may hold in this area.
This is a CODA Podcast that was recorded at CODA2022. Want more content about SCI? Visit neuroresus.com or subscribe to be notified of new podcast releases via email.
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia.
In this podcast Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
The perennial debate of which osmotic agent to use to reduce elevated ICP still rages on.
Who better than Mr Deranged Physiology himself, Aleks Yartsev, to take us through the pros and cons of each and work out a practical strategy.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
A Talk by Amal Abou-Hamden on intracerebral haemorrhage (ICH) and the latest developments in the management of this devastating form of stroke, including the ongoing EVACUATE trial, a randomized controlled trial of ultra-early, minimally invasive, haematoma evacuation versus standard care within 8 hours of intracerebral hemorrhage.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email.
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com.
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com.
Oli Flower talks to Mark Newcomb and Lee Fineberg about the upcoming Developing EM conference in Cartagena, Colombia. March 9-11, 2020. All the details are here:
https://developingem.com
Top 10 critical care papers of recent times
Dr Paul Young
From CICM Trainee Symposium 2019
Dr David Anderson: Medical ethics / organ donation.
Dr Angelly Martinez: Quality / committees.
Dr Chris Mason: Informatics / EMR / committees.
Dr Alex Psirides: Quality / director’s perspective.
Dr Claire Seiffert: Education / simulation.
Dr Paul Young: Research / director’s perspective.
From CICM Trainee Symposium 2019
How I manage: Productivity and self-organisation
Dr David Anderson
From CICM Trainee Symposium 2019
How I manage: Passing (and failing) the CICM exams.
Dr Julia Coull
From CICM Trainee Symposium 2019
How to be an awesome ICU registrar (nurse’s perspective).
Mr Nigel Fealy
From CICM Trainee Symposium 2019
Extracorporeal therapies for toxin ingestion.
Dr Darren Roberts
From CICM ICU Updates 2019
Associate Professor Samuel Galvagno: My bloody head: Diagnosis and management of coagulopathy and traumatic brain injury.
From CICM ASM PROGRAM 2019.
Associate Professor Lindy Jeffree: Lifting the lid on decompressive craniectomy.
From CICM ASM PROGRAM 2019.
Professor Andrew Udy: Emerging neuromonitoring techniques in TBI.
From CICM ASM PROGRAM 2019.
Dr Jonathon Ball: Contemporary management of spinal injury.
From CICM ASM PROGRAM 2019.
Professor Chad Ball: Haemothorax: To drain or not to drain?
From CICM ASM PROGRAM 2019.
Associate Professor Kirsten Vallmuur: Reading between the lines.
From CICM ASM PROGRAM 2019.
Dr Lucian Roseverne: Interventional radiology: standing member or invite only?
From CICM ASM PROGRAM 2019.
Associate Professor Craig French: Erythropoietin & other inflammatory modulators.
From CICM ASM PROGRAM 2019.
Supported by Donate Life
Associate Professor Dianne Stephens: Why do we need a NCCTRC?
From CICM ASM PROGRAM 2019
Dr. Stephen Rashford: Anything a Hospital Can Do; I Can Do First.
From CICM ASM PROGRAM 2019
SESSION 3
FELICITY HAWKER PAPER PRESENTATIONS
Chairs: Dr Matthew Maiden & Dr Raj Goud
From CICM ASM PROGRAM 2019
Dr Nicola Curry & Dr James Winearls: Debate: Goal directed vs Ratio-based Transfusion.
From CICM ASM PROGRAM 2019
CHRISTCHURCH Chair: Dr Ray Raper
Dr James Mckay: What happened, what we did and how we did it…
Dr Louise Hitchings: What we learned, and what we would like you to know.
From CICM ASM PROGRAM 2019.
Monoclonal antibodies (MAbs), guided by molecular studies and personalised medicine are changing the face of clinical medicine. They hold the promise of controlling diseases and improving survival whilst reducing the side effects of some ‘traditional’ therapies. MAbs are being used in conditions familiar to intensivists such as asthma, invasive candidiasis, RSV infection, reversal of novel anticoagulants and clostridium difficile infection as well as in those less commonly seen by intensivists such as multiple sclerosis, migraine, rheumatoid arthritis and numerous malignancies. Side effects of MAb treatment pose particular challenges for intensivists and range from cytokine release syndrome to autoimmune states (such as colitis, endocrinopathies, skin reactions), pneumonitis, thromboemboli, and infections. Pharmcokinetic interactions of MAbs with other drugs remain poorly studied and may be immune dependent, cytokine dependent or target dependent. Our traditional approach of triaging patients for ICU, based on organ failures and ‘prognosis of underlying disease’ is going to be challenged by MAbs with their disease modifying properties and unique side effects.
The incidence of cancer is increasing in line with our ageing population, with a greater number of patients requiring ICU admission for support managing complications of their malignancy, it’s therapy, or conditions unrelated to their underlying cancer. Despite these indications, the presence of a cancer diagnosis has been a common reason for refusal of ICU admission, or admission with treatment limitations.
This session will present the current epidemiology, characteristics and outcomes of patients admitted to Australian and New Zealand Intensive Care Units with cancer, and will describe the change in these outcomes across the last 17 years. Results will be reported for the most common malignancies admitted to ANZ intensive care units, common treatments and complications of malignancy will be reviewed and an agenda for further outcomes research in ICU malignancy will be proposed, with demonstration of early work in the analysis of outcomes relating to specific types of malignancy.
There have been significant developments in the diagnosis and management of ischaemic stroke.
This started with trials showing a benefit for decompressive craniectomy after a malignant hemispheric stroke in patients under 60 undergoing surgery within 48 hours.
The evolution of CT and MRI have enabled us to better image not only the ischaemic core of the stroke, but also the surrounding hypo-perfused brain at risk of ischaemic death; the penumbra. CT and MR angiography now allow rapid, non-invasive detection of occlusions in the major neck and intracranial arterial vessels.
These techniques are key to the appropriate selection of patients for therapeutic interventions aiming at rapid and effective arterial recanalisation to restore blood flow. Intravenous thrombolysis with rt-PA is effective if given early and no later than 4.5 hours. The benefit of intravenous thrombolysis for patients with severe stroke due to large artery occlusion is limited but these patients may be candidates for mechanical thrombectomy. Since 2014, several trials have confirmed the effectiveness of thrombectomy for patients with anterior circulation artery occlusion with a number needed to treat of less than 3 for improved functional outcome. Two recent trials have also shown that in selected patients, the benefit of thrombectomy extends to at least 24 hours, increasing the number of patients eligible to receive this treatment.
The rate of intravenous thrombolysis remains low in many Australian centres, especially in regional areas and only a few metropolitan centres provide a thrombectomy service. With the recent expansion of the time window, the logistics of patients being transferred to these centers has improved but good selection of patients with advanced imaging is a prerequisite to ensure that health resources are used efficiently.
There is a need to improve health services to better manage stroke patients in Australia and worldwide. This has the potential to improve outcome for stroke victims.
People living with HIV in 2018 now have normal life expectancy if receiving Anti-Retroviral Therapy (ART) and often require only one co-formulated pill every day to remain well. However there are still people living with HIV who are unaware of their diagnosis; who may present with a critical illness. Knowing who to test is essential. The population living with HIV are also ageing and often have comorbidities. It is vital that clinical conditions associated with HIV are recognised and for those receiving ART that significant drug-drug interactions are avoided. Pre Exposure prophylaxis (PREP) is widely used to prevent transmission and when to consider post exposure prophylaxis (PEP) should be understood. Although only one person has been cured of HIV ongoing research continues.
Hepatitis C treatment has been revolutionised with Direct Acting Antiretrovirals (DAAs) that are taken in an outpatient settings, however treatment rates in Australia are in decline. Patients living with Hepatitis C need to be identified to be treated. Those patients with established severe liver disease may remain at risk of decompensation and therefore it is considered vital to ensure linkage into adequate follow up. Drug interactions are important to recognise in patients completing DAAs and although Hepatitis C can be cured the management of any coinfections with blood borne viruses requires careful attention.
Blood Pressure (BP) is one of the vital hemodynamic parameters that we often aim to optimize for critically ill patients. Our decisions regarding BP targets, and ensuing use (or avoidance) of vasopressor agents, may directly impact on outcomes for these patients. Despite being a fundamental tenet of critical care, there is a lack of quality evidence to suggest optimal BP targets or to guide the use of vasopressors for individual patients with shock. A mean arterial BP (MAP) of 65-70 mmHg is an often-cited initial BP target for patients during vasopressor therapy. Use of vasopressors to maintain MAP of 65 mmHg or greater remains one of the core clinical criteria in the new definition of septic shock. However, such standard targets are unlikely to be applicable to all patients, many of whom would have a basal MAP higher than 65-70 mmHg, often to a varying degree, during their usual pre-illness state. Therefore, a vasopressor therapy guided by standard BP thresholds may result in a variable degree of untreated relative hypotension, which is associated with new-onset acute kidney injury (AKI). From a physiological standpoint, any relative reduction in net perfusion pressure across an organ’s vasculature can overwhelm its autoregulatory mechanisms, which are already under stress during a shock state. In a recent major RCT, among patients with chronic hypertension, targeting a higher MAP of 80-85 mmHg, versus 65-70 mmHg, showed a lower incidence of subsequent AKI, but with no difference in mortality. However, this RCT did not take patients’ pre-illness basal BP into account, making it difficult to extrapolate these results to those patients with chronic hypertension, who usually have a well-controlled basal BP, or to those patients, who although have a higher-than-normal basal BP but are not formally diagnosed with hypertension. Accounting for a patient’s pre-illness basal BP can minimize variation in the degree of untreated relative hypotension that is often inadvertently accepted in conventional care. It is a simple, but untested, strategy. Further, new tools that can monitor cerebral autoregulation in real-time are on the horizon and have shown some promise in suggesting an optimal BP for individual patients with shock. This technology can further help adjust the initial BP target as a patient deteriorates or recovers from the shock state.
Recently, several novel glucose-lowering targets have had drugs developed. This has resulted in several new drugs that have been approved for the local market to treat hyperglycaemia in patients with type 2 diabetes.
This presentation will attempt to provide:
- A concise summary of these drugs for an Intensive Care Physician.
- A pragmatic framework for what the non-Endocrinology Doctor should do with these drugs whilst the patient is in, and being discharged from, the Intensive Care Unit.
- An outline of current trials evaluating glycaemia in the Intensive Care Unit.
Frailty is a state of reduced physical, physiological and cognitive reserve. Tools to measure frailty which were developed in geriatric medicine practice, have over recent years been applied to patients admitted to the Intensive Care Unit (ICU). Studies in the ICU suggest that frailty is associated with reduced reduced likelihood of discharge home and reduced survival at one year. Survivors also report lower quality of life measures on both physical and mental assessments. The most common of frailty assessment tool used in the ICU, is the Clinical Frailty Scale which has also been recently adopted by The Australian and New Zealand Intensive Care Society (ANZICS) as part of routine data collection on all ICU admissions. Last year, for the first time 39 sites submitted data about frailty on over 10,000 ICU admissions. Frail patients were more commonly older women admitted with medical diagnoses. Even after adjusting for age, medical co-morbidities and acute severity of illness, frailty was an independent predictor of mortality.
This presentation will outline current Choosing Wisely projects happening in ICUs around Australia. It will also discuss the Choosing Wisely Australia campaign and its direction.
International outcomes of centres performing ECLS (extracorporeal life support) are highly variable due to differences in patient selection, cannulation technique, practitioner experience and hospital volume. We describe the experience of one of the first regional intensive care units in Australia to provide both VV (veno-venous) and rescue VA ECMO (veno-arterial extra-corporeal membrane oxygenation).
Methods
Review of internal registry and description of processes and procedures in an 11 bed regional general ICU without on-site cardiothoracic surgery.
Results
Over a 3.5 year period 21 patients received ECLS (90 ECMO days) with an overall 55% survival. All cannulations were peripheral. 4 patients were retrieved from peripheral site. 8 patients subsequently transferred to quaternary centre. Overall survival for VV ECMO was 64% (n=11), rescue VA ECMO (n=12, 8 from E-CPR) 33% survival.
Conclusion
Provision of ECLS (extracorporeal life support) in large regional centres is possible with outcomes similar to high volume centres if established with realistic goals, limitations, and referral pathways to a supportive high volume referral centre. Advantages include timely establishment of life support without the inherent delays of long distance weather dependent aero-medical retrieval and ability to stabilise and prognosticate at the local site. Straight-forward VV-ECMO can be entirely provided at a regional site whilst highly complex patients can safely await further transfer. Regional ECLS provision facilitates appropriate patients receiving ECLS at an optimal time that minimises excessive morbidity.
Since the H1N1 influenza pandemic of 2009 there has been a dramatic increase in the number of patients receiving ECMO and in the number of hospitals that provide it. Data from the Extracorporeal Life Support Organisation (ELSO) suggests that over the last decade the number of adult patients receiving ECMO for respiratory support has increased at least 12-fold and the number of centres submitting data to the ELSO registry has tripled.
The approach to the provision of ECMO in NZ and Australia has been very different, with Australia seeing a huge increase in the number of ECMO centres since 2009 (there are now at least 17 centres in Australia) whilst NZ has continued to have a single national service based in Auckland.
Multiple studies suggest a significant outcome benefit for patients treated at high-volume ECMO centres (defined as those with >30cases per year) compared with “occasional” users and guidelines from the UK, NZ and elsewhere recommend that its use be restricted to expert centres that integrate ECMO within a specialist service providing care for patients with severe acute lung disease that have the capacity to transport these patients safely on ECMO if required.
This session will discuss the evidence for the perceived “volume effect” and the challenges of providing a comprehensive retrieval service.
I will consider this question in two parts;
-
Should ECMO be considered for all patients?
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Should ECMO services be provided in all ICUs?
From a patient perspective, ECMO is a highly invasive intervention and like every other intervention that we consider, the benefits it provides must outweigh its risks for it to be worthwhile.
Clearly, veno-venous and veno-arterial ECMO supports are very different beasts – the patient profile, physiology, complications and outcomes differ considerably. At the extreme of the VA-ECMO spectrum is ECMO-CPR (e-CPR).
Whilst ECMO centres nationally and internationally have published indications and contraindications (which will be discussed), to make decisions around an individual case it is helpful to understand the burden that ECMO support imposes.
For patients this is the physiological burden of being placed on ECMO. This includes frequently the need for ongoing sedation and lack of mobility, the non-physiological cardiorespiratory effects conferred by ECMO, the complications at insertion and during support that patients are exposed to and the uncertain long-term outcomes. These will be discussed further.
The next question is whether all ICUs should be providing this service. The demand for this technology appears to be growing steadily, as is the expectation by other specialties within the hospital for an in-house ECMO service.
Again considering burdens imposed, housing an ECMO programme impacts workload and flow by utilising significant bed-days at the expense of other services that need to be provided, education and credentialing requirements for staff and a financial cost for these resource-intensive patients. These will be discussed individually.
Lastly, the patient outcome implications of centre volume for this highly specialised service will be debated.
Use of Ventricular Assist Devices (VAD) and heart transplantation (HT) for end stage cardiac failure have increased significantly in recent decades. These support strategies hold inherently different risks in the face on non-cardiac critical illness, and require multidisciplinary team management.
According to INTERMACS, more than 2500 VADs/year are implanted the USA. Most implanted devices are continuous flow left-VADs (75%) which deliver systemic cardiac output directly related to pump speed and inversely related to pressure gradient across the pump. Improved survivorship has resulted in increasing outpatient management, however 12-month mortality is 12%, and <30% of patients are major-event free for 1-year. Critical illness may be device related, including cerebrovascular accidents, gastrointestinal bleeding, infection or multi-organ system dysfunction. Alternatively, presenting complaints may be unrelated to the device, with 23-27% of VAD patients undergoing non-cardiac surgery during support. Regardless of etiology, patient management is inherently linked to optimizing device function. Maintaining Left-VAD flow depends on adequate preload, supported right ventricular contractility and afterload reduction whilst managing systemic vascular resistance. Attention to associated coagulopathy, anti-inflammatory therapy and early institution of anti-microbial agents should be considered.
HT is established therapy for end-stage heart failure, with more than 5000 HT reported to ISHLT in 2015. Complexity has increased due to comorbidities and recipient age. Etiologies of critical illness for HT patients include post-transplant complications such as acute rejection, graft failure and cardiac allograft vasculopathy. Acute rejection episodes affect >1/4 of patients within 1-year post-transplant. Systemic illnesses may also be associated with chronic immunosuppression, for example malignancy and unusual presentations of infectious disease; as well as medication toxicity where the post-transplant medication cocktail exacerbates underlying renal insufficiency and multi-organ dysfunction. Therapeutic interventions must also take into consideration potential drug-interactions. Recognizing and managing critical illness in the post-transplant population is exacerbated by vagal denervation blunting normal heart rate response, obscuring illness severity and limiting augmentation of cardiac output.
Both cardiac transplantation and durable mechanical support with ventricular assist devices (VADs) have a parallel history – poor results to begin with followed by progressively improving results with more targeted immunosuppression, better recipient selection, improved diagnosis and treatment of rejection and opportunistic infections (cardiac transplantation) and a major step forward with replacement of pulsatile pumps by continuous flow devices (VADs).
Heart transplantation continues to be regarded as the gold standard therapy for end stage heart disease and that is why there is a rather artificial VAD indication classification – bridge to decision, bridge to transplantation and destination therapy. It is the dynamic nature of heart failure and its treatment that may mean a VAD patient may move in and out of these designations. This would argue for a single designation – indication for a VAD.
The automatic assumption that patients who have a VAD implanted should proceed with listing for cardiac transplantation (in the absence of transplant contraindications) is now coming into question. Comparing the survival of cardiac transplantation versus that of VADs is a difficult statistical problem but there is now evidence that for a subset of patients who have undergone a VAD implant that over the short term their survival may be equivalent to that of a patient receiving a heart transplant. Of course that does not say anything about quality of life and long term survival but at least there is evidence that in the short term there may be equivalent survival which makes decision making both easier and harder. The decision becomes easier in that equivalent survival means that some VAD patients don’t automatically have to be considered for transplantation but harder in the sense that it is unclear which VAD patients may be better keeping their device rather than proceeding to transplantation. That is one of our current challenges.
This talk with discuss the indications for, contraindications to, and expected outcomes after heart transplant with a focus on the New Zealand and Australian experience. I will discuss the transplant assessment process and listing criteria. Perioperative and long term management of heart transplant patients will be covered. Post heart transplant outcomes (morbidity and mortality) will be discussed.
I will discuss organ donation with a focus on the donor heart, covering what criteria we use to determine if a heart with be suitable for transplant.
At the end of the talk attendees will have an understanding of which patients are likely to benefit from heart transplantation and the short and long term outcomes after transplant.
Talk will discuss the use of ECMO as advanced cardio-pulmonary resuscitation in the setting of refractory cardiac arrest.
The aim will be to provide useful information for those already experienced in ECPR as well as those with no experience but an interest in establishing an ECPR in their adult centre.
Topics covered will include the rationale for the use of ECPR , the evidence base and current Australasian practice.
Practical issues re patient selection , cannulation , post cannulation management of haemodynamics , monitoring and ongoing management of the ECPR patient will be covered.
Potential future directions for ECPR will conclude the talk.
Extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (ECPR) is an effective therapy to improve outcomes for children who experience cardiopulmonary arrest. Survival after ECLS varies between 60% and 75%. For ECPR survival is lower, with 40% to 50% of children surviving ECPR. After ECPR good neurological outcomes are seen in 40% to 60% of children. This contrasts with adult patients where neurological outcomes after ECPR are poor. Given these findings the American Heart Association has included ECPR in their 2015 guidelines for children who experience an in hospital cardiac arrest (IHCA).
Several modifiable and non-modifiable factors have been identified as influencing outcomes after ECPR. Location (in-hospital versus out-of-hospital[OHCA]) of cardiac arrest as well as pre ECLS CPR duration impact survival. For children, OHCA is generally viewed as a contraindication. However patients who achieve intermittent output during their OHCA may still qualify for ECPR, particularly if they show signs of good cerebral perfusion during the CPR event. Whether the duration of pre ECLS CPR impacts survival is debated, with studies showing conflicting evidence for and against an observable effect. Duration of in-hospital CPR should therefore not serve as a decision making guide whether ECLS is offered to patients or not.
Post resuscitation care equally raises challenges: targeting normothermia has become a clinical standard, but what oxygenation (which can be independently selected via ECLS) should be aimed for remains unclear.
The organisational structure of a hospital-based ECPR program influences patient survival and must be tailored to the respective institution’s ECLS experience. ECPR eligibility should be anticipated, possibly for any patient entering the hospital. There must be clear agreements for inclusion and exclusion criteria, the latter including severe cerebral injury (hypoxic, metabolic or haemorrhagic), end stage terminal illness or uncontrollable haemorragic disease.
ECPR confers a clear survival benefit for children, but due to logistic requirements remains challenging to implement.
Patients admitted to the ICU after cardiac arrest have, by definition, achieved ROSC. In such patients the major issues remain those of ongoing support hemodynamic and cardiorespiratory support, cerebral protection, aetiological diagnosis, and rapid intervention to deal with the underlying trigger (coronary angiography and stenting of coronary artery disease or CT pulmonary angiography and anticoagulation/thrombolysis for PE). Once the aetiological diagnosis has been made and its cases addresses and cardiovascular stability has been achieved, the priority of care is directed toward cerebral protection. Previous randomized controlled trials had suggested that hypothermia would deliver superior neurological outcomes compared to usual care. However, methodological concerns led to a further large trial of strict normothermia (TTM-1) which found strict normothermia to be equivalent to hypothermia in terms of neurological outcomes. Such findings have led to the design and randomization of patients with out of hospital cardiac arrest (OOHCA) to normothermia vs. avoidance of fever (TTM-2). At the same time preliminary work has demonstrated the potential of hypercapnia to act as a cerebral protector in patients with OOHCA. His has now led to a large trail called TAME, which currently also recruiting patients worldwide and in ANZ. These two trials will provide important information on the outcome of OOHCA patients and may identify new ways of achieving cerebral protection in this setting.
The good news in resuscitation is that there have not been any new advances that mandate a change in practice since the 2016 ANZCOR Guidelines. The bad news is that despite our best intent, the ever-increasing research appears unable to demonstrate improved outcomes with any particular approach. Two of the most exciting areas (eCPR and post-resuscitation care) are being covered in detail at separate talks at this meeting. This presentation will focus on updating the audience on the more continuous approach to evidence evaluation, and the key recent publications that have made us at least re-evaluate our practices in BLS (including ventilation), ALS (including anti-arrhythmics) and peri-resuscitation care.
The Fellowship abroad: Dr Peta Alexander
Research Fellowship: Dr Elissa Milford
Simulation Fellowship: Dr Sile Smith
Trauma Fellowship: Dr Fraser Magee
Echo Fellowship: Dr Sebastian Knudsen
There has been a potpourri of papers released in the last 12 months of interest to Intensivists. Some have solved the great mysteries of the universe, some have sparked the interest for more high-quality research and others have left us scratching our heads. This talk will give a snapshot of the Top 10 Critical Care papers of the last year.
Basic bronchoscopy skills are considered a core component ability for all Intensive Care trainees. A few simple tricks to remember anatomy can make a relative bronch novice look like a seasoned pro. Remember 4 rules when looking down a bronchoscope:
- Walls to the back
Every bronchus looks the same as every bronchus once you have already jumped in, so always identify the posterior wall to orientate yourself
- Carina is your friend –visit her often.
Everyone gets lost. When this happens, don’t go on, go back to the carina
- The right middle lobe and lingula are anterior anatomical structures
When you look down a scope, the right middle lobe is not in the middle, medial or any other stupid word beginning with ‘m’……….it is anterior, seriously!
- The apical segment of the lower lobes is a posterior anatomical structure.
The fact that you even know this thing exists will so impress your colleagues and boss that no one will dare ask you any other bronchoscopy anatomy questions.
This short talk will focus on the who, why, how, what, and when of diagnosis and management of pulmonary hypertension and the right ventricle:
- Who gets pulmonary hypertension?
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Why is pulmonary hypertension important?
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How do I diagnose pulmonary hypertension?
- What are the most important practical management strategies?
- When should I use advanced monitors and expensive pharmacotherapies?
Both acute and chronic pulmonary hypertension will be discussed, and the emphasis will be on practical management of patients in the intensive care environment.
The understanding around the metabolic response to the stress of critical illness has evolved rapidly over the past decade.
This involves a neuroendocrine and an inflammatory component, which results in perturbations within the sympathetic nervous system, the hypothalamo-pituitary axis and the immune system.
The clinical consequences are widespread and include changes in metabolic rate, altered use of macronutrients as energy sources, stress hyperglycaemia, muscle wasting and changes in body composition. Many of these manifestations are akin to the metabolic syndrome observed in ambulatory populations. Medium to long-term effects of these metabolic disturbances involve bone health, cognitive and behavioral alterations.
Knowledge of these effects is relevant due to the potential therapeutic implications, which will be discussed.
The Australian population away from metropolitan areas has the same health care needs and deserves the same level of care (within available resources) as urban residents: we can and should provide it.
This short talk aims to explore work in a non-tertiary centre ICU as a career option and why it’s worth considering. It will look at what life and work are really like in non-metropolitan areas and how and why working in a regional ICU can be a rewarding career. It will try and dispel some misconceptions as well as present some of the challenges (and how to overcome them) that arise while working outside capital cities. This is meant to be a light-hearted look at living and working in the bush or on the beach and an insight into a career path often overlooked by city-based trainees, not a hard-core recruitment drive or a critique of urban life/tertiary centre work. Come along with an open mind and have a look: you may discover a lifestyle and workplace you didn’t realise could suit you, for the short or longer term.
To pass the Second Part Exam, your performance needs to be at the expected level for a junior consultant. You need to be able to rapidly synthesise clinical information from multiple sources to reach a differential diagnosis and appropriate management decisions. (And achieve this while feeling the equivalent of standing at the top of an Olympic downhill ski-run, simultaneously suffering from a severe bout of gastro.)
Some general pointers include:
Get experience running the unit and calling the shots
Establish a good knowledge base - don’t just practice SAQs
Write and share your own SAQs and Vivas
Make every case you see at work a practice Hot Case
Teach everyone else
Consider performance coaching
Finally, if things don’t go to plan the first time, remember it’s an exam not a statement on who you are as a person. Work out what worked and what didn’t and why to change your approach and come back stronger.
10% of patients admitted to ICU die and, in some societies over 80% of people die during a hospitalization that included an ICU stay. Most deaths in ICU are predictable and the overwhelming majority of patients are comatose for the last few days of their life. Most communication by intensivists is directed at families rather than patients. This talk will cover some scenarios where this isn’t the case and give guidance on delivering bad news to and discussing organ donation with awake patients.
According to the World Health Organization Training Package for the Health Sector (2008), ‘Children are not little adults’ and specialised care must be targeted to pediatric patients in order to optimize outcomes. In a review of Australia and New Zealand Paediatric Intensive Care (ANZPIC) Registry data from 2006 to 2016, approximately 1600 children <16 years old were admitted each year to one of 21 adult ICUs in Australia and New Zealand who voluntarily submit data. This represents at least 17% of all children (<16 years) admitted to an ICU for care. Respiratory etiology of critical illness was the most common reason for admission (48%), followed by neurological diagnoses (15%) and trauma (11%). According to the ANZPIC data, children from 1 month to 5 years old make up 61% of the admitted patients. Of the total 17 686 children admitted to an adult ICU over the 11 year period, 15 727 (89%) were discharged home directly, 330 (2%) died in the adult ICU, and 1625 (9%) were transferred to tertiary PICU for ongoing care. This data suggests that modern Australia and New Zealand adult ICUs provide a significant proportion of Intensive Care therapies to Australasian children. In this session we will discuss some of the key anatomical, physiological and developmental differences of relevance to critical care of the infant and child. In particular, the translation of common intensive care principles will be highlighted to empower well trained adult intensive care physicians to apply their skills and knowledge to critically ill children.
You are called to see a 62-year old male now 3 hours post CABG x 4 with hypotension and escalating vasoactive requirements. As you arrive to the bedside, he arrests. How do you manage this situation?
This talk outlines the management of cardiac arrest in the intensive care unit post open heart surgery, as per the CALS (Cardiac Advanced Life Support) algorithm. Key differences from the standard ALS (Advanced Life Support) algorithm are highlighted, including delaying CPR by up to 1 minute to troubleshoot the initial rhythm, the role of emergency resternotomy, and avoidance of 1mg doses of adrenaline.
The prevalence of degenerative valvular disease is increasing in the context of an increasingly ageing population, and despite advances in medical and surgical interventions, is associated with a significantly worse outcome when compared with the general population. Data from the EuroHeart Survey (2003) suggests the commonest relates to native valve disease (predominantly aortic stenosis) however, more than one quarter of patients with valve disease have undergone a previous intervention. According to current guidelines, in general treatment for severe, symptomatic aortic stenosis is surgical aortic valve replacement, which is associated with excellent outcomes, however, despite this around 30% of such patients do not undergo surgical intervention.
The last decade has seen a significant change in the potential therapeutic options for patients with aortic valve disease due to the development of transcatheter techniques for valve implantation. Patented in 1991, the first successful human implant of a transcatheter aortic valve was undertaken in 2002, with currently >500,000 implantations having been undertaken in >70 countries worldwide. The evidence supporting transcatheter aortic valve implantation (TAVI) otherwise known as transcatheter aortic valve replacement (TAVR) came originally from the key PARTNER studies, where patients judged to have inoperable aortic stenosis who underwent TAVI having improved survival and a reduction in hospital admission at 1 year. Following the early safety and efficacy studies, and following increasing recommendations for TAVI as an option for patients at high risk in international guidelines, the use of transcatheter techniques is extending to those of lower risk.
The title of the talk is emblematic of the binary way that we have approached structural heart disease where cardiac surgery or an interventional procedure might be required – this thinking is now transitioning to an entirely different paradigm which is that of the “Heart Team”.
Remarkable advances over the last decade have led to a plethora of interventional options for both coronary and structural heart disease. In the coronary realm, as complex and high risk PCI options continue to evolve, the role for surgery in multi-vessel disease, diabetes and LV dysfunction has become well established. Hybrid revascularization options also evolve and are the subject of ongoing investigation. In structural heart disease, as TAVR application expands to a low risk subset, ongoing investigations will answer questions regarding durability of TAVR as compared to the historical surgical gold standard. Mitral valve repair remains the gold standard for degenerative MR and the Mitraclip has become a well-established option for a high-risk subset. Ongoing studies will answer the role of Mitraclip in functional MR and excitingly multicenter studies are investigating a role for transcatheter mitral valve replacement for mitral valve disease. The role of surgery in tricuspid valve disease, a large and underserved subset remains controversial and transcatheter devices remain investigational at this point. The reality is that decision-making is complex and central to the entire debate is the heart team concept, whereby surgeons and interventionalists sit at the same table as part of the same team to determine the best approach for any given patient. As evidence continues to evolve, lines between cardiac surgery and interventional cardiology continue to blur, with combined expertise from both sides going forward required to best serve our patients in a truly heart team approach.
CARDIAC REVASCULARIZATION SURGERY IN THE ELDERLY: AN EVIDENCE-BASED HEALTH ECONOMIC APPROACH
Background: Increasing prevalence of chronic disease in the context of an ageing society has led many to question the value of cardiac revascularization surgery and associated intensive care in elderly (octogenarian) populations. However societal expectations of improved technology and its likely impact on longevity and improved quality of life suggest there is a demand for cardiac surgery in this population. Elderly people are more likely to hold private health insurance, therefore the cost (in terms of waiting time) is likely to be low.
Objectives: This presentation will consider the value of cardiac revascularization surgery from a health economic perspective, including the various perspectives of patient, family/significant others, providers, healthcare sector and society.
Method: A theoretical evidence-based health economic model will be presented that is relevant to the evaluation of cardiac surgery in an elderly population. This will be combined with a review of the literature and existing data sources as evidence-based inputs into the development of an economic model to assess cost effectiveness in terms of cost per quality adjusted life year saved. Studies included will be recent published trials (post 2010) where costs and/or quality of life outcomes have been compared between cardiac surgery and conservative management in an elderly (80+ years) population.
Results/Conclusion: Recent literature and study results will be reviewed against the theoretical health economic model. Where evidence and/or data exist that meet inclusion criteria for the economic analysis these will be summarised in the model. Where gaps in evidence exist these will be highlighted, including appropriate strategies to address data deficiencies.
A/Prof Jennifer Watts
Health Economics
Faculty of Health
Deakin University
Introduction: Recent times have witnessed almost half, or sometimes more cardiac surgical procedures are performed in patients above 75 years of age. Traditionally, the EuroSCORE II and STS risk scoring systems have been widely used across the globe. Extensive reviews have shown that EuroSCORE II probably overestimates the perioperative risk at lower score levels while the STS score tends to underestimate the risk.
Frailty is a broad term that encircles aspects of nutrition, lack of agility, inactivity, lack of strength and wasting; and is seen in 25-50% of elderly patients. It has been defined as a geriatric syndrome reflecting a state of reduced physiological reserve and increased vulnerability to poor resolution of homeostasis after a stressor event. Conversely, pre-frailty, which is potentially reversible, is associated with higher risk of older adults developing cardiovascular disease.
Frailty assessment includes a variety of physical and cognitive tests, functional assessments and evaluating nutritional status. Literature has highlighted what is referred to as the ‘obesity paradox’, meaning obese patients with heart failure fair better than leaner patients, possibly because they have more metabolic reserve and also because weight loss in itself is a risk factor for frailty.
Patient Selection: To comprehensively assess a patient, factors that describe the biological status of the patient should be incorporated. There are various methods of assessment and modified Fried criteria or comprehensive assessment of frailty are a couple of systems commonly used.
Conclusion: Systematic reviews have shown that frail patients have higher chance of mortality, major adverse cardiac and cerebrovascular events and functional decline after cardiac surgery. A holistic assessment not only categorises patients into the apt risk category and hence match goals and treatments; but also, will pick up patients with pre-frailty who will benefit from multidisciplinary intervention and be better prepared for the intervention.
"The real benefit to the patient [of echocardiography] is not the technical skill, but rather the application of intellectual input... information, communication and teamwork are essential" Jos Roelandt, 1993
Of all the imaging techniques used in intensive care, echocardiography has come to the fore, in particular due to its accessibility, immediate availability and applicability as a point-of-care technique, thereby removing the risks of transportation of the critically ill. Over the preceding 20 years evidence has continued to emerge for its extended use in the acute/emergency setting, to the extent that it is now included in national and international guidelines relating to the universal definition of myocardial infarction, as well as in shock pathways, and as an adjunctive technique in advanced life support. Its potential scope is huge, with applications relating to monitoring, cardiac pathophysiology and coronary perfusion as well as its more evident use to define cardiac anatomy.
The three main uses of ultrasound to interrogate the heart relate to the way in which the technique is used: first, as an extension to the clinical examination using binary questions and 2D imaging only (focused cardiac ultrasound, FoCUS) which forms the basis of 'basic' techniques. Second, incorporating the full range of echocardiographic techniques for diagnostic capability (echocardiography), and third, selective application of the full range of techniques in order to answer specific questions raised in the critical care/emergency arena (targeted echocardiography). This includes speckle strain/strain-rate to determine abnormalities of myocardial function suggestive of myocarditis, calculation of myocardial electromechanical efficiency in order to maximise cardiac output, recognition of parameters that suggest restrictive right ventricular physiology, with the requirement for modification of ventilatory techniques and parameters, detection of myocardial ischaemia, estimation of LVEDP and LAP, and its application in the institution, monitoring and weaning of mechanical circulatory support.
Key questions for the clinician undertaking echocardiography in the critical/acute/emergency setting can be summarised in a checklist format, which includes:
Background questions:
- What is the clinical context?
- What does the treating clinician want to know (ie why won't the patient wean from mechanical ventilation? or is this pulmonary oedema, and if so, why?).
- Can echocardiography answer the required question, and what is the accuracy in this setting?
- What is the underlying diagnosis (cardiac and non-cardiac)?
- How is the patient being sedated/ventilated/supported
Specific echocardiographic data:
- What is limiting the cardiac output/elevating the venous pressure?
- Is the left atrial pressure elevated?
- Is the heart rate/AV delay/VV delay appropriate?
- Is there any other relevant information that the treating clinician needs to know that may inform planned interventions?
To reach its full potential in the critical arena demands therefore not only understanding of the whole range of echocardiographic techniques, but also the confounding factors that will be found in this setting, including filling status, ventilatory parameters, mechanical support and the use of vasoactive agents. Although frequently 'simplified' for application in FoCUS, expert echocardiography in this setting can be extremely challenging, and the potential to cause harm to the patient through misinterpretation should not be underestimated.
The goal of hemodynamic monitoring is to assess the cardiovascular state of the patient, define their reserve and monitor response to treatments and time. Resuscitation efforts are essentially aimed at restoring and sustaining tissue wellness through maintaining an adequate amount of oxygenated blood flow to the metabolically active tissues. We need to monitor pressure, flow and function. To accomplish these goals one must be able to measure arterial pressure and all its components (i.e. waveforms), cardiac output and stroke volume as well as the adequacy of flow. Presently, there are several devices that can estimate the arterial pressure waveform from a finger plethysmographic device. They are very accurate until profound circulatory collapse makes peripheral pulse not representative of central pressures. These devices can also estimate stroke volume by intuiting the arterial pressure waveform in a fashion similar to that performed by the numerous minimally invasive hemodynamic monitoring devices we now have now. These non-invasive devices can quantify functional hemodynamic monitoring dynamic parameters. Also, pulse oximeter pleth density signals vary with pulse volume into the finger or skin and the pleth variability can also be used as a surrogate of pulse pressure variation. Furthermore, bioreactance can measure both cardiac output and intrathoracic fluid content through surface electrodes. Finally, end-tidal CO2 transiently varies with venous return, increasing if blood flow increases. So both eh bioreactance device and end-tidal CO2 can be used to identify cardiac output changes in response to a passive leg raising maneuver. Thus, one can measure arterial pressure waveforms and cardiac output continuously, assess volume responsiveness and monitor therapy. Finally, the dynamic changes in tissue O2 saturation (StO2) measured by near infrared spectroscopy of the thenar eminence during a vascular occlusion test defines peripheral circulatory insufficiency and local blood flow independent of arterial pressure. Furthermore, heart rate variability decreases with increasing cardiovascular stress and can be readily measured in real time from the R-R intervals of the surface ECG signal. Finally, the measure of urine output, skin temperature and sensorium all define effective tissue blood flow as reasonable end-points to resuscitation, if the patient is not overwhelmingly ill. When these measures are coupled to a treatment approach know to improve outcome, there is little reason to believe that such completely non-invasive approaches will be inferior to invasive ones in the management of the critically ill patient.
Many tools are nowadays available to monitor patients’ hemodynamics in the intensive care unit (ICU) and in the operating room (OR) settings. Some monitoring tools are invasive such as the pulmonary artery catheter (PAC), some others are less invasive such as transpulmonary thermodilution (TPD) systems, some others are called minimally invasive such as uncalibrated arterial pulse wave analysis (PWA) devices, and some others are non invasive such as volume-clamp method, applanation tonometry, esophageal Doppler, bioreactance, CO2 rebreathing, and pulse wave transit time. Recently, the European Society of Intensive Care Medicine has provided recommendations about the use of hemodynamic monitoring in patients with shock. To summarize, except the PAC and the TPD systems, the other hemodynamic monitoring tools are not recommended for the two following reasons: 1) they provide cardiac output but not other important hemodynamic variables, although some of them also provide stroke volume variation (SVV) or pulse pressure variation (PPV), and 2) their validity has been questioned in cases of shock requiring vasopressors. The uncalibrated PWA devices or esophageal Doppler seem to be more suitable in the OR setting when no vasopressor is used. The advantage of the PAC is to provide pulmonary artery pressure and pulmonary artery occlusion pressure. The advantage of TPD systems is to provide global end-diastolic volume (a measure of global cardiac preload), extravascular lung water (a measure of lung edema), pulmonary vascular permeability index (a measure of lung capillary leak), cardiac function index (a measure of systolic cardiac function), PPV and SVV (dynamic indices of fluid responsiveness). The PAC and TPD systems are indicated in cases of shock either when the patient also has a severe ARDS initially or when the shock state does sufficiently respond to the initial therapy administered on the basis of clinical examination, central venous oxygen saturation, carbon dioxide pressure gap, PPV and echocardiography.
With increasing survival comes morbidity. Pulmonary hypertension in the critical care population represents a secondary disease of myriad pathologies for children and adults. Whilst often cardiac failure or respiratory disease complicated by pulmonary hypertension, the exact aetiology of secondary pulmonary hypertension can be a diagnostic challenge. Yet an understanding of the pathophysiological basis for pulmonary hypertension may allow for patient guided therapy and predictions of reversibility.
With pulmonary vasodilators of various mechanistic and non-specific sites of action backed by limited disease specific clinical evidence, are we in the jungle treating secondary pulmonary hypertension or can one management regime encompass all critical care patients?
The right ventricle (RV) is not important, until it is. Under normal conditions RV function merely keeps central venous pressure low and delivers all the venous return per beat into the pulmonary circulation under low pressure. If pulmonary artery pressures increase due to pulmonary vascular disease (embolism, ARDS, COPD), over-distention (COPD, asthma) or ischemia (embolism, pulmonary hypertension), the RV rapidly dilates decreasing left ventricular (LV) diastolic compliance via ventricular interdependence. Most clinicians presume that the RV is merely a weaker version of the LV, but follows that same rules. But this in not true. Normally, RV filling occurs without any measurable change in RV distending pressure owing to conformational changes in its shape rather than distention of its wall fibers. This effect allows central venous pressure to remain low despite major dynamic change sin venous return associated with breathing. RV ejection is exquisitely dependent of RV ejection pressure. Thus, if disease processes increase pulmonary artery impedance then RV dilation and failure will eventually occur. Furthermore, most of RV coronary blood flow occurs during systole, unlike LV coronary blood flow, which primarily occurs in diastole. Thus, systemic hypotension or relative hypotension where in pulmonary artery pressures equal or exceed aortic pressure must cause RV ischemia. Clinically these findings carry a common end result. For cardiac output to increase RV volumes must increase. If increasing RV volumes also result in increasing filling pressures then RV over distention may be occurring causing RV free wall ischemia. If relative systemic hypotension exists then selective increases in arterial pressure will improve RV systolic function. Accordingly, fluid resuscitation, if associated with rapid increases in central venous pressure should be stopped until evidence of acute cor pulmonale is excluded. Acute cor pulmonale can be treated by improving LV systolic function, coronary perfusion pressure or reducing pulmonary artery outflow impedance. The normal response of the RV to slowly increasing pulmonary artery pressures is to increase its intrinsic contractility (Anrep effect), but if the pressure load exceeds such adaptation, RV hypertrophy develops in an asymmetric fashion initially in the infundibulum before progressing to the RV free wall and septum. In chronic RV failure, dilation and RV wall thinning occurs as the heart reverts to preload to sustain stroke volume (Starling effect). Importantly, all these effects and their response to therapies can be assessed at the bedside using echocardiography and pulmonary arterial catheterization.
The two major causes of acute right ventricular (RV) failure in ICU patients are acute cor pulmonale (ACP) during acute respiratory distress syndrome (ARDS) and ACP during acute massive pulmonary embolism (PE).
The increase in pulmonary vascular resistance (PVR) in ARDS can be secondary either to « structural » mechanisms related to lung injury per se and to « functional » mechanisms related to the effects of mechanical ventilation with positive end expiratory pressure (PEEP). The latter mechanism is enhanced when PEEP overdistends more than it recruits lung volume and when tidal volume (VT) is high. The recommended protective ventilation with low VT and PEEP adjusted to driving pressure can also reduce the RV afterload. A reduced central blood volume can also play a role in the increase in PVR (extension of the West’s zone 2). In this case, volume administration can reduce the PVR and improve the RV function. Finally, prone positioning also exerts a beneficial effect on RV afterload through a decrease in PVR (lung recruitment, decrease in hypoxic vasoconstriction, increase in central blood volume with decrease in the extent of zone 2).
In acute PE, RV dysfunction is associated with poor outcome. Thrombolytic treatment, which is indicated in cases of severe PE with shock, prevents hemodynamic decompensation in patients with intermediate risk PE, but also results in increased risk of severe hemorrhage and stroke. In the case of PE with low cardiac output and no RV dilatation, fluid administration can be indicated to improve cardiac output. In cases of systemic arterial hypotension, vasopressors such as norepinephrine can be indicated to restore adequate RV perfusion pressure. Indication of inotropic agents such as dobutamine, which improves the RV-pressure artery coupling should be evaluated individually. Surgical pulmonary embolectomy can be indicated when the thrombolytic therapy is contra-indicated in acute PE with shock.
The use of extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VADs) for both short-term and long-term management of advanced cardiac (and respiratory) failure is increasing. Both thrombotic and haemorrhagic complications are common in patients receiving mechanical support, and such complications are associated with increased morbidity and mortality. Risks of bleeding and of thrombosis vary over time, and according to technical and patient factors. Careful assessment of the risks and benefits of anticoagulation for each patient is therefore a critical component of successful mechanical support.
The approach to anticoagulation for patients receiving VADs varies according to stage of recovery and device. In the immediate post-operative period, bleeding is usually a greater risk than thrombosis and a period free from anticoagulation is usually used. Subsequent initiation of anticoagulation is usually with heparin, with the introduction of warfarin and aspirin over a period of days. Current recommendations include warfarin for all continuous flow devices, usually with the addition of aspirin, and in some cases an additional antiplatelet agent. Target INR and platelet inhibition varies with device, and institution. Testing varies according to device also. Potential pitfalls and problems exist, and these will be highlighted in this session, using a case-based approach.
The management of anticoagulation for patients receiving ECMO varies worldwide, and there are currently limited guidelines. Important factors in decision-making in regards to anticoagulation for ECMO include mode of ECMO, ECMO configuration, ECMO flows, and underlying patient pathology. Strategies for anticoagulation should take each of these factors into consideration. It is also important to recognise that other management techniques to avoid thrombosis are important, such as adequate intracardiac decompression, and promoting cardiac ejection to avoid stasis. Cases will be used to demonstrate important issues and practical management strategies.
Venous thromboembolism (VTE) is one of the most preventable complications in hospitalised patients. Critically ill patients are at risk of VTE due to coexisting of multiple risk factors but, at the same time, often at risk of bleeding. Though not common, fatal pulmonary embolism (PE) continues to occur [1] – due to the alignment of failures (or ‘holes’) in each defensive layer according to the Swiss cheese model [2]. Tackling this is not easy because the pattern of the ‘holes’ in each layer of the cheese is different between patients and, to complicate the matter further, both the size and location of the ‘holes’ also change with time in each individual patient.
In brief, fatal PE occurs due to one of the three failures – failure to prevent, failure to diagnose and failure to treat (aggressively). It is well established that anticoagulants are very effective in reducing VTE. The golden rule to reduce the size of the ‘holes’ in prevention is to use a multimodal approach, with anticoagulants as a key player. The bottom line is that any anticoagulants, even at a reduced dose, is better than no anticoagulant. Judging bleeding risk to determine when anticoagulant prophylaxis can be safely initiated solely based on INR or aPTT is a last century practice. As for diagnosing PE in the critically ill, computed tomography pulmonary angiography (CTPA) is the practical gold standard. While contrast-induced-nephropathy (CIN) is real and critically ill patients are certainly at risk, the benefits of a CTPA will almost always outweigh the risk of CIN when intensivists suspect their patients may have PE (or when the pre-test probability is >10-15%)[3,4]. Immediate aggressive systemic anticoagulation is pivotal in confirmed PE. It is better to aim at a higher aPTT (80-100s) target than a lower one (e.g. 60-80s) as soon as possible to avoid clot propagation which may lead to requiring even higher risk therapies, such as thrombolysis, extracorporeal membrane oxygenation (ECMO) or surgical embolectomy. For those unfortunate few individuals who continue to deteriorate despite systemic anticoagulation, the options ‘to lyse, suck, use ECMO, or remove’ are endless; but in reality the choice is often limited by what expertise is most available at the time of crisis.
Finally, the controversial issue of using inferior vena cava filters as a primary VTE prophylaxis in patients with contraindications to anticoagulants will be discussed, including the results of our recently completed randomized controlled trial [5].
References:
[1] Ho KM, Burrell M, Rao S, Baker R. Incidence and risk factors for fatal pulmonary embolism after major trauma: a nested cohort study. Br J Anaesth 2010;105:596-602.
[2] Reason J. Human error: models and management. BMJ 2000; 320: 768-70.
[3] Ho KM. Balancing the risks and benefits of using emergency diagnostic radiocontrast studies to diagnose life-threatening illness in critically ill patients: a decision analysis. Anaesth Intensive Care 2016;44:724-8.
[4] Ho KM, Harahsheh Y. Predicting contrast-induced nephropathy after CT pulmonary angiography in the critically ill: a retrospective cohort study. J Intensive Care 2018;6:3.
[5] Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, Holley A, Kop A, Geelhoed E, Corcoran T. Detailed assessment of benefits and risks of retrievable inferior vena cava filters on patients with complicated injuries: the da Vinci multicentre randomised controlled trial study protocol. BMJ Open 2017;7:e016747.
Survival in patients with advanced heart failure (AHF) has improved over the last 2 decades. An increasing number of patients however, are dying with progressive heart failure over the same duration. Optimal utilization of medical therapies and devices like implantable defibrillators and biventricular pacemakers are the likely reasons patients are surviving longer albeit with progressive HF.
Evolution in mechanical circulatory support (MCS) devices has occurred over the same period, such that they can now be rapidly instituted providing support for pump failure, often percutaneously, with timely restitution of physiologic and metabolic derangements with fewer complications.
MCS devices can be classified as Short term and Long term. Short term devices such as Intraaortic balloon pumps (IABP), Impella ®, TandemHeart® or Venoarterial extracorporeal membrane oxygenation (VA – ECMO) using a Cardiohelp® device, are usually employed as ‘Bridge to Recovery’(BTR) or Bridge to Decision’(BTD), usually in acute settings. Long term devices such as implantable left ventricular assist devices (LVADs) e.g. Heartmate II® & 3®, Heart ware HVAD® are implanted as ‘Bridge to transplant’ (BTT) or ‘Destination therapy’ (DT) usually in patients ‘sliding’ on inotropes when they are transplant eligible (BTT) or ineligible (DT) respectively.
Ventricular assist devices have traditionally been developed for left ventricular support in case of severe left heart or biventricular dysfunction. Historically, right ventricular (RV) dysfunction following LVAD implantation or as a component of biventricular dysfunction was managed with either medical therapy, temporary VADs (i.e. ECMO configuration with continuous flow centrifugal pumps like CentriMag®, Rotaflow ®) or occasionally with LVADs placed on the right side. Recently the Impella RP® and ProtekDuo®, percutaneously placed pumps with inflow in the inferior vena cava & right atrium respectively and outflow in pulmonary artery, have become available as less invasive options, for short term RV support.
The Syncardia® is the only approved total artificial heart system currently in use; however various biventricular, total heart systems (e.g. BiVACOR®) in development show promise.
Mechanical circulatory devices provide attractive, viable, physiologically plausible ventricular support options that can be used effectively in carefully selected patients.
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
Patients admitted to the intensive care unit (ICU) are at increased risk for cardiac arrhythmias. They may be the reason for admission or resulting from the underlying condition. Treating exacerbating and contributing factors is the first step in management, however in certain cases may not be sufficient. Further the diagnosis of the arrhythmia may difficult from the ECG. An invasive cardiac electrophysiology study (EPS) can be helpful in establishing the diagnosis and can be combined with catheter ablation to eliminate the substrate. The field of cardiac electrophysiology is rapidly developing with technological advances providing insights into the mechanism of certain arrhythmias and expanding the therapeutic potential. This presentation will provide an overview of recent developments and insights into the management of common arrhythmias on the ICU.
The intent of this presentation is to provide an update of coronary assessment and management for the adult intensivist. Discussion points will include:
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An assessment of coronary severity, using established methods, in particular fractional flow reserve (FFR),
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Which stent- highlight the evolution of the stent to the current generation and what is evolving,
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How to keep the stent open with current concepts of antiplatelet therapy and how this impacts the critically ill patient
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What to consider if the ECG is abnormal, but the coronaries are not flow limiting obstruction- an occasional dilemma in the critically ill patient and finally
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Discussion around a contemporary study regarding cardiogenic shock and coronary ischemia.
Debate: Who should care for GUCH?
Presenters: Dr Susanna Price & Dr Peta Alexander. Moderator: Dr Bennett Sheridan
Congenital Heart Disease (CHD) in infants presents as inadequate systemic or pulmonary blood flow, or heart failure from intra-cardiac shunts. Approaches to surgical intervention comprise primary repair, early palliation with subsequent repair or definitive palliation.
CHD palliation evolved in the pre-cardiopulmonary bypass era. In 1938 a patent ductus arteriosus was ligated, in 1944 pulmonary blood flow was established via subclavian artery to pulmonary artery anastomosis (Blalock, Taussig and Thomas), and in 1952 pulmonary artery banding was employed to protect pulmonary vasculature. In the 1950s-60s symptomatic infants underwent these palliative procedures with reparative intra-cardiac interventions delayed due to perceived risk. In the late 1960s emerging publications shifted the focus to early primary repair.
An exponential increase in the complexity of surgical repairs over the past 50 years have built on early innovation, exemplified by management of transposition of the great arteries. Surgical approach transitioned from palliative atrial switch procedures (Senning 1957 and Mustard 1963) with low early mortality but impressive late morbidity to the reparative arterial switch procedure (Jatene 1975) which remains standard of care.
Despite advances in the field, biventricular repair is not an option for all patients. Children born with a single functional left ventricle benefited from staged palliative procedures to the Fontan circulation. First described in 1971, the Fontan procedure established passive pulmonary blood flow, using the single ventricle for systemic circulation. Further innovation by Norwood (1981) facilitated similar staged palliation of patients with single right ventricles. While for most patients with functionally univentricular CHD, staged palliation is dictated by underlying anatomy, it is increasingly recognized that a proportion of these patients may have anatomy and physiology amenable to biventricular circulation.
As we embark on the next era of innovation in CHD, patient selection, multicenter collaboration and meaningful outcome measures are challenges to be addressed.
Inotropic agents are commonly used in critically ill patients to support myocardia contractility either in the setting of cardiac surgery or ischemia or in the setting of sepsis associated myocardial dysfunction. The most commonly used agents are beta-agonist drugs (dobutamine), mixed beta and alpha agents (adrenaline and dopamine), phosphodiesterase inhibitors (inodilators) such as milrinone or enoximone or calcium sensitizers (levosimendan). Such agents are currently used according to clinician and/or unit preference based on tradition, mentorship, belief, inductive physiological reasoning, familiarity, understanding of pharmacokinetic and pharmacodynamics properties, side effects, and cost. No randomized controlled trials exist to support the notion that treatment targeted to similar physiological outcomes (ie cardiac index or MVO2) with one drug versus another would yield a different clinical outcome. More recently, however, two double-blind RCTs have compared adjunctive inotropic therapy with levosimendan in patients with post-operative low-cardiac output syndrome or low pre-operative ejection fraction. Both found that the addition of levosimendan was not superior to the edition of placebo.
Acute heart failure (AHF) is defined as rapid onset of new or worsening signs and symptoms of heart failure. It represents a life-threatening condition requiring treatment for fluid overload and hemodynamic compromise. Presentation may be initial diagnosis with symptoms and signs of AHF or acute decompensation of pre-existing cardiomyopathy. Hemodynamic instability results from disorders of the myocardium, valves, conduction system or pericardium, in isolation or combination. Potentially treatable causes, e.g. acute coronary syndromes, must be diagnosed and managed early for restoration of function.
Physiological changes associated with AHF result in reduced cardiac output and end-organ hypoperfusion. Once potentially treatable causes are managed, stratification of patients by clinical presentation guides further therapeutic intervention. AHF patients can be categorized as either ‘wet’ or ‘dry’ by clinical fluid status assessment, and either ‘cold’ or ‘warm’ according to perfusion status. In combination, these features identify four patient groups (‘warm-wet’, ‘warm-dry’, ‘cold-dry’, ‘cold-wet’) that guide therapy and facilitate prognostication. ‘Warm-dry’ patients rarely require intensive care for AHF treatment but may benefit from escalation of oral therapeutic regimen. Patients who examine as ‘cold-dry’ may benefit from fluid challenge, and/or inotropic agent infusion. ‘Warm-wet’ patients present with predominantly congestive or hypertensive symptoms which benefit from diuresis and vasodilatation. Patients who present ‘wet-cold’ with normal blood pressure (SBP >90) may benefit from vasodilators and diuretics, with inotropic agents for refractory symptoms. Hypotensive ‘wet-cold’ patients (classic cardiogenic shock) require inotropy with or without vasopressor agents, effective diuresis and early consideration of mechanical circulatory support (MCS).
Definitive therapies for AHF depend on underlying cause, and may include coronary artery intervention, valve repair, rhythm control to restore atrio-ventricular synchrony or management of pericardial tamponade. Patients with severe AHF not responsive to standard therapies should be considered for temporary MCS while candidacy for more durable option is explored by the multi-disciplinary team.
In non-cardiac ICU patients, the two major causes of acute myocardial dysfunction are sepsis-related cardiac depression (SRCD) and stress-related cardiomyopathy, the most common cause being the former. The main mechanisms responsible for SRCD include release of cardiac-depressant substances such as pro-inflammatory cytokines, hyporesponsiveness of beta-adrenergic receptors, decreased sensitivity of the myofilament to Ca++, and excessive production of perioxynitrite. Echocardiography is the best method to diagnose SRCD. If a cut-off value of 45% left ventricular ejection fraction is used to define SRCD, the occurrence of SRCD is 60% in septic shock patients (40% on the day of admission and in 20% the two following days). Recent advances in ultrasonography such as speckle-tracking (measuring the longitudinal systolic strain) may allow detecting cardiac abnormalities that are not detected by conventional echocardiography. Even when the SRCD is diagnosed, an important issue is to decide to treat it since left ventricular dilatation is an adaptive mechanism associated with a good outcome. The Surviving Sepsis Campaign suggests using dobutamine in patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents. In our opinion, it is more logical to give an inotrope when the shock state persists in the presence of: 1) proven SRCD with echocardiography and, 2) either low (mixed or central) venous blood oxygen saturation or increased veno-arterial carbon dioxide pressure gradient. Dobutamine is still recommended as the first-choice inotropic agent. Levosimendan is considered an alternative as it can restore the sensitivity of the cardiomyocyte myofilament to Ca++. Early administration of norepinephrine can not only increase blood pressure through an alpha1-adrenergic effect but also improve cardiac contractility through a beta1-adrenergic effect and/or an increase in the diastolic arterial pressure (i.e. the perfusion pressure of the left ventricle).
Ventricular pump function is often compromised during critical illness and for a variety of reasons. The most common cause of a limited cardiac output in acutely ill patients is right ventricular (RV) dysfunction. Exacerbations of chronic obstructive lung disease or the use of high end-expiratory pressure sin acute lung injury to support arterial oxygenation can result in acute elevations of pulmonary arterial pressure impeding RV ejection, causing RV dilation, decreased left ventricular (LV) diastolic compliance. All these effects limit cardiac output and LV stroke volume. Importantly, the treatment is to sustain mean arterial pressure greater than pulmonary artery pressure to prevent RV ischemia and balance RV fluid status to avoid both over-distention (acute cor pulmonale) and under-filling. This delicate fluid balance is greatly facilitated by the immediate and repeated use of bedside echocardiography. Attempts to minimize lung over distention should be a primary focus of therapy. If one focuses only on the LV, these patients would be said to have a reversible form of diastolic dysfunction, in that LV ejection fraction would be normal but the LV not able to increase its end-diastolic volume without excess filling pressures promoting pulmonary edema. The second most common etiology of impaired heart functional reserve is chronic LV hypertrophy secondary to hypertension, wherein systemic afterload reduction is the primary treatment. Third, decreased systolic pump function is often seen in sepsis owing to reduced myocardial adrenergic responsiveness. However, this is often under-appreciated because of the usually co-existent peripheral vasodilation. In septic patients, measures aimed primarily to increase mean arterial pressure, such as the use of vasopressors often results in a decrease in cardiac output because the septic heart is not able to handle the increased load. Importantly, this form of systolic dysfunction is reversible once the sepsis state resolves, but may require inotropes during its height to sustain flow under pressure. Finally both chronic heart failure patients can also get sick and acute myocardial infarction will impair both diastolic and systolic function. Their treatments include reversing coronary ischemia, if present, afterload reduction and a balanced fluid response. A clear and logical approach to all critically ill patients is needed to quickly separate these diverse forms of heart failure from each other as they have markedly different therapies and clinical trajectories.
Over 65,000 people are diagnosed with heart failure every year in Australia. Heart failure is implicated in the deaths of 61,000 individuals per year. Although the need for cardiovascular support is common in patients in the Intensive Care Unit (ICU) with about 60% of ventilated patients requiring some form of inotropic or vasopressor support, a primary diagnosis of acute heart failure on admission to ICU is much less common. There are about 3000 ICU admissions per year primarily due to cardiogenic shock, cardiomyopathy or congestive heart failure in Australia and New Zealand. This represents 2% of all ICU admissions. Only a minority of these patients have a prior history of significant cardiac disease. The mortality of these three conditions are 40%, 17% and 14% respectively. Since the early 2000’s there has been a progressive decline in risk adjusted mortality of all patients admitted to ANZ ICUs. However, the decline in mortality for patients with acute heart failure has lagged behind other diagnoses. This gap is widening.
Shree Basu and Ahmed Osman discuss paediatric traumatic brain injury. They cover initial management, prevention of secondary injury, what is different in paediatrics compared to adults and the latest evidence.
From www.IntensiveCareNetwork.com
Resuscitation is complicated, but the solutions don't have to be. These are the psychological hacks that will help you conquer complexity and excel in dynamic environments.
Shree Basu is joined by Marino Festa to discuss sepsis. They cover epidemiology, challenges in diagnosing sepsis, SEPSIS 3 guidelines and what it means in paediatrics, and some clinical tips on the assessment and management of children with sepsis.
Here's a useful articleon the prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit.
From www.IntensiveCareNetwork.com
My own experience by Ms Claire Kerr.
Ms Kerr is a nurse who also spent significant amounts of time in hospital as an adolescent. Claire outlines her own experience in the hospital system and the things that made a difference for her.
In this episode Shree Basu and Ahmed Osman discuss the shocked neonate - both the initial management when they present and the subsequent PICU management. From IntensiveCareNetwork.com
In this episode Shree Basu and Ahmed Osman discuss the tricky issues surrounding management of paeds CICU patients with a single ventricle. From IntensiveCareNetwork.com
Shree Basu and Lily Foster are paediatric intensive care trainees. They discuss post operative management in paediatric cardiac intensive care following surgery for congenital heart disease.
Matt Anstey is an intensivist from Sir Charles Gardener hospital in Perth, Australia. He gave this talk on outcomes after intensive care at an ICN WA meeting in Perth last year.
Shree Basu and Lily Foster are paediatric intensive care trainees. They give an introductory podcast to paediatric cardiac intensive care, covering recognition of congenital heart disease, early and emergency pre-operative management principles, and classification of the most common lesions.
A quick interview with Mark & Lee from Developing Emergency Medicine giving some information about the 2018 Developing Emergency Medicine conference in Fiji. The conference will be held ath the InterContinental Fiji Golf Resort & Spa on Nataola Bay, from Monday 3rd December - Thursday 6th December 2018, with the two day ultrasound workshop the weekend prior.
Hepatic resections are complex surgical procedures harboring a significant risk for complications. In line with the continued development of liver surgery, hepatic resections tend to be more complex and extensive, with to this associated enhanced risk for post-hepatectomy liver failure (PHLF). Despite these improvements in outcome after major liver resection, PHLF remains one of the most serious and fatal complication of major liver resection occurring in up to 8 % of the cases.
Multiple factors increase the risk of PHLF but in clinical practice the risk of PHLF is closely associated with the assessment of the pre-operative Future Liver Remnant (FLR). Accordingly the prevention of PHLF is alleged to be affected by the induction of hypertrophy of the liver remnant via portal vein embolization or ligation if the expected functional left remnant in cases where the FLR is judged too small. An alternative therapeutic strategy is to perform a two-stage procedure allowing the FLR to grow after the first non-curative resection.
Irrespective of these surgical-technical advancements, early recognition and initiation of supportive care is crucial to improve patient outcomes in PHLF. Despite its fatal consequences, the complexity behind the pathogenesis of PHLF remains poorly understood and treatment options (except for preventive measures) are limited. The advent of extra corporeal, albumin-based liver-dialysis system (Molecular Adsorbent Recirculating System, MARS) seemed to offer a treatment modality for patients with liver failure being either acute or acute on chronic (ACLF). The information on the use of MARS in PHLF is meager and basically no experiences have been reported with the use of well-defined criteria for liver failure. For instance Van de Kerkhove et al. reported on five patients treated with MARS due to unspecified PHLF, of whom 3 improved but only one survived. We have recently compiled our experience with MARS treatment for well-defined PHLF and found that four out of 13 patients survived (31%) three months postoperatively. However, this survival figure rose to 44% (4/9) if the analysis was confined to patients with primary PHLF fulfilling the Balzan criteria alone. These results formed the basis of a prospective clinical trial with the objective of evaluating early and consistent MARS treatment in patients with primary PHLF. Results from this study will be presented and discussed
References
Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The "50-50 criteria" on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Annals of surgery. 2005;242(6):824-8
Stange J, Mitzner S, Ramlow W, Gliesche T, Hickstein H, Schmidt R. A new procedure for the removal of protein bound drugs and toxins. Asaio J. 1993;39(3):M621-5.
Gilg S, Escorsell A, Fernandez J, Garcia-Valdecasas JC, Saraste L, Wahlin S Nowak G, Stromberg C, Lundell L, Isaksson B. Albumin dialysis with MARS in post-hepatectomy liver failure (PHLF): experiences from two HPB centers. Surgery Current Research, 2015, 6: 252.
Management of the patient with decompensated liver disease is clearly more straightforward in specialist centres with multi-disciplinary input, access to liver transplantation teams and advanced technology. Bioartificial extra-corporeal liver support systems are undergoing evaluation and include the extra-corporeal liver assist device (ELAD developed by Vital Technologies).
ELAD is an investigational, extra-corporeal, human cell-based system. The human liver-derived cells (VTL C3A) may mimic certain functions of in vivo human liver cells. The principles of operation of the ELAD system are as follows: plasma ultrafiltrate is passed through hollow fibre cartridges containing human liver-derived cells (VTL C3A cells) and allowing two-way transfer of toxins, metabolites and nutrients, mimicking liver function. Toxins, such as bilirubin, glucose and oxygen pass from the ultrafiltrate to the VTL C3A cells. Treated plasma ultrafiltrate is then reconstituted with blood cells and returned to the patient. Data evaluating this system shows trends indicating a potential for ELAD to increase survival rates in selected patients with decompensated liver failure.
Issues in the management of liver failure include cardiorespiratory support, and the management of cerebral oedema. The principles for haemodynamic support are as for most critically ill patients, with early restoration of organ perfusion and use of vasopressors if hypotension persists despite restoration of volume. For the patient with liver failure, lactate-containing solutions and fluid overload should be avoided. New monitoring techniques for encephalopathy have been developed, including brain tissue oxygen tension, continuous EEG, transcranial Doppler and cerebral microdialysis.
Key issues for regional centres are basic management principles, liaison with specialist centres and timing of transfer. Who and when to refer is a difficult problem for the regional Australasian unit, given the tyranny of distance and issues relating to retrieval and transfer of the critically ill patient. Early liaison with the regional liver unit is key.
The patient with chronic liver disease presents a range of potential challenges when a severe intercurrent illness occurs or major surgery is required. Even well-compensated liver cirrhosis in high functioning patients renders such individuals vulnerable to a myriad of problems when physiological stressors occur. Severe acute liver failure is another clearly defined sydrome in which extremely rapid and complex multiple organ failure typically ensues. Whilst intensivists are familiar and adept with the management of other major organ failure, new acute liver failure or decompensated chronic liver disease is particularly difficult to manage due to the inherent breadth of roles that the liver has in maintaining health as well as the current lack of comprehensive support therapies other than organ transplantation. While effective artificial life-supports for severe respiratory, cardiac or renal failure are available in the intensive care setting, support for over liver failure is less straightforward. The failing liver inevitably and rapidly impact on every other organ system, necessitating a systematic and comprehensive approach when planning patient care.
As with any dynamic and complex disease process, management is optimised when major clinical problems are anticipated and the detrimental impact is mitigated by the timely application of effective interventions. For patients with severe acute liver failure, a knowledge of the cause, disease trajectory, severity of organ failure as well as early interventions to prevent cerebral oedema are likely to improve outcomes. Specific treatments such as temperature management, respiratory support, osmotherapy and blood purification may be readily applied and reduce the risk of poor outcomes. In the setting of decompensated chronic liver disease, identifying reversible causes of deterioration and proactively managing the resulting predictable problems will ensure the best chance for recovery or stabilisation until subsequent transplantation. The majority of patients can be effectively managed in non-transplant centres, however it is also essential to identify those patients for whom orthotopic liver transplantation is the best or only option for survival. Early discussion with a transplant centre may assist intensivists in deciding who should be transferred and guide the timing of retrieval.
Despite the publication of a number of studies over recent years looking at energy delivery and outcomes in the critically ill population we remain uncertain how best to determine optimal calorie delivery for our patients. The concept that energy delivery should match energy consumption is plausible and intellectually attractive bu Broadly speaking clinicians can be divided into 3 categories according to their approach on energy delivery to the critically ill. Some believe that optimal clinical outcomes are achieved by closely approximating energy consumption i.e. providing full calorie requirement, usually around 2000kcal/d for the standard sized adult. This position is supported by a number of observational studies, however, patients usually only receive about 60% of what they are prescribed. Some believe that attempting to provide full feeding exposes the patient to the risk of overfeeding and that ‘permissive’ underfeeding is safe and better tolerated in critically ill patients where gastrointestinal function is frequently deranged. Interestingly, recent data suggest that the patient group potentially most at risk of overfeeding are those who are malnourished at presentation. Finally, some believe that the amount of energy delivered during ICU stay has little impact on recovery. Only when the ICU stay becomes unusually prolonged may the amount of energy delivered become important. There is evidence to suggest that some nutrition should be given enterally from early in the ICU stay to provide gastrointestinal mucosal protection and improve subsequent gut function. In recent years there have been several randomised controlled trials addressing energy delivery but they have unfortunately given conflicting results. Furthermore, these studies have had a number of limitations including: being underpowered to show an effect on survival; open to bias because of being open-labelled; most have not delivered full energy requirements so the effect of this on outcomes remains uncertain. It is hoped that many of these issues will be addressed in the currently recruiting TARGET trial which will be completed next year.t, while energy delivery can be measured with indirect calorimetry, this is not a technique that lends itself to routine clinical care. Accurate measurement or calculation of day to day energy expenditure is not currently routinely possible. Delivery of nutrition is an important supportive activity in the ICU. Patients generally receive less than prescribed nutritional needs and there is no robust evidence as yet to suggest that this is deleterious to outcomes.
The 105 years since the first successful thoracic oesophagectomy was performed saw initially slow progress in terms of operative mortality, morbidity and oncological outcomes. Even until the late 1990’s, operative mortality figures of 15-20% were commonplace and long term survival was poor, as low as 12%1. The last 20 years has seen a major change in these outcomes both within Australia and overseas. These improvements have been based on the bed rocks of improved surgical techniques, improved peri operative care, changes in the distribution of the pathophysiology of the disease, improved patient selection through better staging, Development of endoscopic techniques for early tumours, development of effective neo adjuvant regimes and the development of “high” volume centres have all contributed to the current figures of 4% preoperative mortality and overall 5 year survivals in the post surgical patient of 40%. Better understanding of the nutritional issues involved has led to an emphasis on better quality of life issues in both the curative and palliative settings. This talk outlines the forces that have brought about the changes including outlining the modern treatment algorithm and discussing the volume effects of surgery in the Australian context
- Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67: 381-90
According to a quote variably attributed to Niels Bohr, Yogi Berra, Albert Einstein, Mark Twain and others ‘prediction is difficult; especially about the future’. Nevertheless, in an era of evidence-based medicine, one might surmise that the future of management of GI bleeding in the ICU will be informed by large-scale high quality RCTs. There are a number of such trials on the horizon that give us a pretty good idea of what the future holds. Based on my best-guess of what these trials will show I predict that in the future we will:
1. Use more TXA in patients with GI bleeding.
2. Use less stress ulcer prophylaxis.
The Haemorrhage ALleviation with Tranexamic acid (TXA) – InTestinal system trial (HALT-IT) is a pragmatic trial that will compare TXA to placebo in 8000 participants with clinically significant gastrointestinal bleeding. The rationale for this trial is that decreasing fibrinolysis with TXA will increase clot stability, improve haemostasis, and reduce rebleeding, leading to reduced mortality for patients presenting with GI bleeds. Additional information about the role of TXA will come from a second trial, the EXARHOSE trial, which will investigate the safety and efficacy of TXA in cirrhotic patients with acute upper GI bleeding.
There are two large-scale RCTs comparing proton pump inhibitors to placebo coming soon. The first is the SUP-ICU trial, which is being run by the Scandinavian Critical Care Trials Group. This trial will enrol adult patients with one or more risk factors for upper GI bleeding and has a primary end point of day 90 mortality. The second is the REVISE trial which includes patients who are mechanically ventilated in ICU and expected to be ventilated the day after tomorrow. REVISE has a primary end point of ‘clinically significant GI bleeding’. Together SUP-ICU and REVISE have a combined sample size of over 8000 participants and will help us to better understand the effects of PPI use on mortality risk, GI bleeding risk, VAP risk, and C. diff infection risk. The results of these trials will be complemented by the PIC-UP trial which will investigate the role of stress ulcer prophylaxis in PICU patients and the PEPTIC trial which compares PPIs and H2RBs in mechanically ventilated adults.
Peptic ulcer bleeding (PUB) carries a 10% risk of death within 30 days and accounts for 36–46% of emergency upper gastrointestinal bleedings (UGIBs). The annual incidence of hospitalization due to PUB is 19–57 per 100,000 persons. Most of these patients undergo esophago-gastro-duodenoscopy (EGD), estimated to 2000 patients in Denmark alone every year. The poor prognosis in PUB is partly due to the clinical condition itself, and partly due to the high prevalence of medical comorbidities. Hence, optimizing pre-, intra-, and post-endoscopic patient management are likely to be important in order to minimize the risk of death and improve outcome. Although duodenal ulcer (DU) and gastric ulcer (GU) seem to be identical diseases with a considerable overlap in both risk-factor profile and clinical manifestations, ulcer site could potentially affect outcome. However, the prognostic importance of ulcer site has not been extensively evaluated, and existing knowledge is ambiguous. Two systematic reviews of predictors of re-bleeding after endoscopic treatment reported that posterior DUs and ulcers on the lesser gastric curvature more often were associated with haemostatic failure. A recent cohort study reported that bleeding DU was associated with poorer outcome than bleeding GU in terms of mortality, need for surgery and readmission. However, another large cohort from Hong Kong did not find that DU site was associated with increased mortality. Limited data exist on the prognostic importance of ulcer site in patients with PPU. In a nationwide cohort study comprising more than 24,000 Danish patients with complicated PUD, a significantly higher 30- and 90-d all-cause mortality rates were found, and more re-interventions in patients with bleeding DU compared with patients with bleeding GU, suggesting that ulcer site is an important predictor for poor outcome in patients with PUB. In patients with PPU, no significant association was seen between ulcer site and mortality or re-intervention. Finally, the proportion of GU increased slightly over time. Critically ill patients in the intensive care unit (ICU) are at risk of clinically important gastrointestinal bleeding, and acid suppressants are frequently used prophylactically. However, stress ulcer prophylaxis may increase the risk of serious adverse events and, additionally, the quantity and quality of evidence supporting the use of stress ulcer prophylaxis is low. The aims of some recent trial have been to assess the benefits and harms of stress ulcer prophylaxis with a proton pump inhibitor in adult patients in the ICU. It has been hypothesized that stress ulcer prophylaxis reduces the rate of gastrointestinal bleeding, but increases rates of nosocomial infections and myocardial ischaemia. The overall effect on mortality seems to be unpredictable.
At this year's CICM ASM in Hobart, Tasmania, there will be the second CICM trainee symposium. This is a day of lectures and discussions targeted specifically at CICM ICU trainees and immediately precedes the CICM ASM meeting itself. More details are here.
Because of widespread recognition that surgical quality varies widely, there is growing demand from patients, providers, and payers for better measures of surgical outcomes. Risk-adjusted mortality rates are a simple and reliable measure of surgical quality and have been used to good effect in cardiac surgery. One way to improve outcomes measurement in non-cardiac surgery is to combine several operations together when assessing hospital mortality rates. While previous studies show relatively weak relationships between outcomes for different medical diagnoses, there is some reason to believe these relationships may be stronger in surgery. Many high-risk operations are dependent on the same hospital-level resources, staffing, and processes of care. Findings suggest that procedure-specific mortality is strongly related to a hospital’s mortality with other operations. In some cases, mortality with other operations is a better predictor than other proxy measures of quality, including hospital volume. The main result, that hospitals good at one operation tend to be good at others, has important implications for measuring the quality of non-cardiac surgery. Structural characteristics important to all high-risk operations include intensivist staffing of critical care units, high nurse to patient ratios, and the presence of high-volume, specialty trained surgeons.
They also depend on many of the same processes of care. Shared processes of care related to patient outcomes include preoperative cardiac evaluation, appropriate use of perioperative antibiotics, beta blockers, and venous thromboembolism prophylaxis, and postoperative pain management. Three specific major GI surgical procedures will be discussed.
Still the primary method of treating patients with esophageal cancer has been surgery. However, the traditional open esophagectomy (OE) procedure has high complication rates resulting in significant morbidity and mortality. Various studies showed in-hospital mortality between 1.2 and 8.8% , even as high as 29%. Minimally invasive oesophagectomy (MIO), which was first described in the 1990s, was attributed to be superior in reducing postoperative outcomes, without compromising oncological outcomes and avoiding thoracotomy and laparotomy. The basis of minimally invasive techniques in esophageal surgery is to maintain the therapy effectiveness and quality of traditional operations, while reducing perioperative injury. Nevertheless, the real benefits of minimally invasive approach for esophagectomy are still controversial. A number of meta-analyses and even randomized controlled trials demonstrated MIO to be superior in reducing risk of postoperative outcomes, but their results are not very consistent, especially on the issue of in-hospital mortality
The second is major hepatectomy which is increasingly used in patients with colorectal liver metastases (CRCLM) and cholangiocarcinoma and the recent figures for postoperative morbidity and mortality suggest wide safety margins. The limits of resection are, however, continuously tested and extended hepatectomy is used to remove larger and larger proportions of liver parenchyma.
In a patient with a normal liver, a small future liver remnant [FLR] may be enough to support a normal functional recovery, whereas in a patient with a diseased liver (e.g., a cirrhotic liver or liver damaged by very extensive chemotherapy), a larger FLR is presumably mandatory to ensure adequate postoperative liver function. Certainly volume and liver disease are not the only determinates of outcome, but careful assessment of liver volume can be used as an accurate measure to reduce the risk of life threatening complications, liver failure and death after major hepatectomies. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has rendered great attention since its introduction. Although showing promising results with unprecedented growth of FLR, both in time and size, the technique has also been subjected to criticism, mainly because of high morbidity and mortality rates. A recent review of the literature shows that the majority of the serious complications affect patients subjected to concomitant biliary surgery, while patients with colorectal liver metastases (CRLM) undergoing ALPPS seem to be less prone to develop high-grade complications.
Finally many studies have shown that resection of pancreatic tumor with venous resection have equal morbidity/mortality compared to when no venous resection is done, at least in experienced hands. The case for arterial reconstructions is not that unanimous but several authors have shown case series that this is a feasible option for longer survival in the right patient, as long as the margin is clear of tumor involvement. The prognosis is worse compared to resections without the necessity to reconstruct the SMA, the celiac trunk or hepatic artery. There is also heterogeneity in the literature regarding the definition of borderline resectability and locally advanced (incurable) pancreatic cancer. Another aspect is that former CT generations seem to slightly overestimate vascular involvement of the tumor but remain accurate regarding the retroperitoneal fat tissue infiltration.
That the gastrointestinal tract exerts an important, but unseen role in the pathogenesis of human disease has been a recurring theme over recorded human history. The Egyptians believed that a factor from the gut known as “ukhedu”, or “something disgusting”, was a factor in disease. At the turn of the century, and based on the ideas of Elie Metchnikoff, the gut was held responsible for the process of aging, and multiple innovative approaches were tried to arrest the passage of time. Following World War II, the gut was proposed to contain a factor (later shown to be endotoxin) that contributed to the hemodynamic arrangements of shock, and 30 years ago, we and others proposed that the gut was the motor of multiple organ failure. Today the focus of studies of the gut in critical illness is on the microbiome, and the way in which illness alters it. Each of these paradigms has generated new pathologic and therapeutic insights.
The human GI tract contains a remarkable number and diversity of microorganisms in intimate proximity to a complex immune network in the gut wall, the liver, and the spleen. It also contains 25 grams of endotoxin – enough to kill 6 million people. Acute critical illness results in striking changes in this flora, reducing the diversity, and increasing the concentrations of many of the species that predominate in ICU-acquired infections. These organisms can invade normally sterile tissues through aspiration or translocation across an intact gut wall. The flora can be altered not only in its composition, but also in the inherent virulence of its constituents, changes that are induced by interactions with the local intestinal environment. A normal flora is essential to the normal development and maturation of the metabolic and immunologic function of the gut. Conversely, an altered flora can contribute to systemic alterations in immune responsiveness, perhaps through interactions with Kupffer cells in the liver. Moreover endotoxin from Gram-negative bacteria can be absorbed following trauma or other states associated with altered splanchnic perfusion.
The spectrum of interventions based on a knowledge of the role of the gut in critical illness is broad. Simple interventions such as early feeding to maintain mucosal integrity are widely used. The impact of other gut-directed measures such as stress ulcer prophylaxis is undergoing re-evaluation. Selective digestive tract decontamination (SDD) has been shown to reduce both rates of nosocomial infection and mortality following ICU admission, but is not widely used for reasons that are not entirely clear. The converse approach – selective colonization either with probiotics or even fecal transplants – is also showing evidence of clinical efficacy.
The gut is one of the most complex, yet one of the most elusive organs of the body. As the locus of the most important interactions between the human and microbial worlds, it remains a source of continuing discovery in critical illness.
Landing a consultant job, requires a different mind set than any job interview you have had prior. As well as your brand new, hard won, consultoid clinical skills, you will now have to interact with HR and Administration. This talk addresses tricks and tips for the interview process. Hints on what to say, and more importantly ...what not to say..
The top 10 trials of the recent past are an interesting bunch highlighting some of the best and worst of evidence-based medicine. While they might not be all you need to know, they are some of what you need to know. Some are practice changing, some introduce new treatment paradigms that may change the way we practice in the near future. Sepsis trials, oxygen therapy in various forms, miracle cures, delirium-o-lysis, levosimendan, angiotensin-II, tranexamic acid, and decompressive craniectomy all feature. Anyone who doesn't think that the literature is interesting is bonkers.
Thrombocytopenia is frequently encountered in the ICU. It is important to have an understanding of the common and important causes of TP as well as to have a simple framework to approach this problem. A simple approach is to identify if TP is expected or unexpected and work through the management that way. Platelet transfusions or repeating the FBC is not always the right approach. Heparin induced thrombocytopenia is frequently considered as the cause of TP. This leads to excessive HITS screen being ordered and risks false positive results.
The management of submassive PE (intermediate risk PE) has been an area of controversy for years. With early evidence demonstrating potential benefit of thrombolysis in both short and long term outcomes. The flipside is the demonstrated increased risk of haemorrhage. Despite this more recent trials have emerged to somewhat quell the thrombo-enthusiasts however it is likely that we still don't have all the answers?
Running CRRT in the ICU presents challenges. To ensure optimum dose of dialysis there are several tricks that can be employed to ensure the dialysis machine runs smoothly. Citrate anticoagulation, pre-dilution, reducing the blood flow and providing a reliable vascath are key to achieving good flow through the dialysis machine.
A/Professor Charlie Corke explores what people value most when it comes to their end of life plans.
This paper explores whether surgeons and intensivists differ through the effect of the “surgical covenant of care”. This covenant is very much a product of the shared journey taken by both surgeon and patient and is well described in medical literature. This literature is reviewed and learnings highlighted. In addition to this covenant, a number of other differences that may impact on how surgeons behave are also explored. These include the culture of surgeons and their training, models of administration for ICU units, the nature of professional decision making and the effects that age, experience and visiting surgical appointments might have on Intensivist- Surgeon relationships in an ICU. Finally, a number of pointers to better inter-professional practice are offered.
Who decides? For thousands of years, doctor knew best, but recently respect for patient autonomy has emerged as a key ethical principle in decision making. This has led to the suggestion that decisions should be shared between patients, families and the medical team. An international consensus conference embraced this model for end of life decision making in ICU. But what is shared decision making, does it improve outcomes and is it legally safe? This podcast suggests that the answer so far is a definite maybe.
A/Professor Neil Orford explores the identification of patients who have poor prognosis at the CICM ASM 2017.
This presentation by Professor Bala Venkatesh is ICU focussed and will cover:
- What categories of patients?
- Impact on the patient
- Impact on the caregivers
- Impact on ICU practice
- Economic costs
- Compliance with stated preferences
- Drivers for this change
- Current level of training
- How we as a speciality should take the lead in education and making the change.
Professor Lars Lundell. Professor of Surgery Karolinska University Hospital Stockholm. What this man doesn’t know about the oesophagus is probably not worth knowing. What he knows about so many other things is worth knowing. Professor Lundell's visit to Australia will not soon be forgotten. His distinct style and his willingness to grasp controversial issues made his multiple lectures at the ASM memorable. From his first talk about critical care aspects of GI surgery to his last asking “Is obesity a surgical disease?” Lars repeatedly surprised the audience. During this recording he again surprises with his commentary upon obesity, bariatric surgery and its future. The talk turns to the real public health problem we have to face and thus to global politics. Lars’ talks are worth seeking out via the CICM website. Indeed Lars had so much interesting stuff to say that this podcast, at 30 minutes, is twice the usual length. Sit back and listen. Each year the CICM holds its Annual Scientific Meeting. The Meeting has always been focused upon a single issue or organ system. This year the theme was Gastroenterology entitled “A Gut Reaction; ICU Gastroenterology from beginning to end.” The lectures presented at the meeting have been recorded and will all be shared among the delegates and some will also be shared with all comers via the Intensive Care Network (www.IntensiveCareNetwork.com), the celebrated “#FOAMed” website. (Free Open Access Medical Education.) The organisers of the ASM invited #FOAMed podcaster/interviewer Dr Doug Lynch to come along to engage some of the leading lights of the meeting in conversation and record them. These recordings are the latest in a series of podcasts/blogcasts playfully called “Jellybeans”. They are entirely spontaneous chats with interesting people; short, completely unscripted, 100% unedited and recorded in one take. It is essentially an uninterrupted live recording. The focus is unapologetically on the quality of the conversation rather than the quality of the audio recording. The host of the interview is a fast talking Irish doctor, a jack of all trades but a master of none, a perpetual student and a trainee of the CICM. The “Jellybean” is an itinerant podcast that regularly appears on www.LifeinTheFastLane.com, www.IntensiveCareNetwork.com and many other websites. Over 100 conversations have been recorded with persons of interest. They are on iTunes and Stitcher Radio. The CICM ASM Jellybean series each start with a biographical component and then the conversation follows its own path. The subject matter is usually that which dwells upon the fringes of intensive care medicine; human factors, education, ethics, equality, gender, personal histories, possible futures and all the other challenges that we so often face. Being so they compliment the lectures but do not attempt to repeat them. We hope you enjoy finding out a little more about the people behind the CICM Annual Scientific Meeting. The four CICM x Jellybean co-branded recordings are part of a larger collection. It is only these four that are formally associated with the College. Doug Lynch is not a representative of the college and any views expressed are his own.
By Steve Morgan & Sophie Connolly Welcome back to the Basic Science Clinic podcast on ICN. Post-hiatus we are ready to reinvigorate the examination of oxygen cascade physiology, from the prevailing atmosphere down to the only organelle that boasts its own bespoke genome, the mitochondrion. In the last podcast we decomposed the minutiae of passive respiratory gas diffusion across the alveolar capillary membrane. Prior to expounding the pre-eminence of V/Q ratios in determining gas exchange sufficiency, we need to publically vivisect the pulmonary circulation to bring you the belated Raw Science 11, pulmonary perfusion. This detailed inspection of pulmonary perfusion is the longest podcast yet, no doubt we got slightly carried away and thus we have broken it up into three more comfortably digested sections. Section 1 (start to 18:24) will include the historical bit and both adult and fetal anatomy. Section 2 (18:30 to 40:26) examines pulmonary haemodynamics and the integrated control of pulmonary vascular tone. Section 3 (40:35 to end) details the protean functions of the pulmonary endothelium and endothelial glycocalyx, the determinants of transvascular fluid flux in the lung, all with reference to the pathophysiology of acute lung injury. The pulmonary circulation participates in gas exchange, blood filtration, metabolic regulation of endogenous vasoactive mediators, drug uptake, metabolism and excretion and the regulation of lung interstitial fluid homeostasis, a dexterous function devastated by the clinical syndrome of ARDS. Understanding the idiosyncracies of the pulmonary circuit is imperative for interpreting heart-lung interactions that influence V/Q distribution & gas exchange efficiency as well as overall cardiovascular performance, particularly during positive pressure ventilation in the context of concomitant shock states.
John takes his life long learning seriously. How many senior professors of surgery brushes up on his Trauma Surgery practice by volunteering to work in Baragwanath Hospital for 6 weeks? John Marshall has been at the pointy end of research, in particular sepsis research, for many years. That has been a rather controversial area in recent times. John has navigated those waters with charm and grace. So we took him aside and tried to find out more about his journey and what it journey it is. From Ingmar Bergman to Chris Hani Baragwanath, from working in local occupational health and safety to InFACT; a global network of huge critical care clinical trial groups. Impressive stuff. Impressive personality. Impressive story. (And caterpillars.) Each year the CICM holds its Annual Scientific Meeting. The Meeting has always been focused upon a single issue or organ system. This year the theme was Gastroenterology entitled “A Gut Reaction; ICU Gastroenterology from beginning to end.” The lectures presented at the meeting have been recorded and will all be shared among the delegates and some will also be shared with all comers via www.lifeinthefastlane.com and the www.IntensiveCareNetwork.com, the celebrated “#FOAMed” website. (Free Open Access Medical Education.) The organisers of the ASM invited #FOAMed podcaster/interviewer Dr Doug Lynch to come along to engage some of the leading lights of the meeting in conversation and record them. These recordings are the latest in a series of podcasts/blogcasts playfully called “Jellybeans”. They are entirely spontaneous chats with interesting people; short, completely unscripted, 100% unedited and recorded in one take. It is essentially an uninterrupted live recording. The focus is unapologetically on the quality of the conversation rather than the quality of the audio recording. The host of the interview is a fast talking Irish doctor, a jack of all trades but a master of none, a perpetual student and a trainee of the CICM. The “Jellybean” is an itinerant podcast that regularly appears on www.LifeinTheFastLane.com, www.IntensiveCareNetwork.com and many other websites. Over 100 conversations have been recorded with persons of interest. They are available on iTunes and Stitcher Radio. The CICM ASM Jellybean series each start with a biographical component and then the conversation follows its own path. The subject matter is usually that which dwells upon the fringes of intensive care medicine; human factors, education, ethics, equality, gender, personal histories, possible futures and all the other challenges that we so often face. Being so they compliment the lectures but do not attempt to repeat them. We hope you enjoy finding out a little more about the people behind the CICM Annual Scientific Meeting. The four CICM x Jellybean co-branded recordings are part of a larger collection. It is only these four that are formally associated with the College. Doug Lynch is not a representative of the college and any views expressed are his own.
Professor Jules Wendon
Jules Wendon is the Professor of Hepatology and Executive Medical Director at Kings College London.
When it comes to the intensive care hepatology there are few people that have done more to shape our knowledge and practice than Jules Wendon. Jules travelled to Australia to share her knowledge at the CICM Annual Scientific Meeting. Sharing is a key theme in this interview as Jules insists on
crediting her team, all of her team, for their part in the success of Kings. Humble yet inspirational, modest yet brilliant. Have a listen to this short conversation recorded in between her lectures at the CICM ASM in Sydney 2017.
Each year the CICM holds its Annual Scientific Meeting. The Meeting has always been focused
upon a single issue or organ system. This year the theme was Gastroenterology entitled “A Gut Reaction; ICU Gastroenterology from beginning to end.”
The lectures presented at the meeting have been recorded and will all be shared among the delegates and some will also be shared with all comers via the Intensive Care Network (www.IntensiveCareNetwork.com), the celebrated “#FOAMed” website. (Free Open Access Medical Education.)
The organisers of the ASM invited #FOAMed podcaster/interviewer Dr Doug Lynch to come along to engage some of the leading lights of the meeting in conversation and record them.
These recordings are the latest in a series of podcasts/blogcasts playfully called “Jellybeans”. They are entirely spontaneous chats with interesting people; short, completely unscripted, 100% unedited and recorded in one take. It is essentially an uninterrupted live recording. The focus is unapologetically on the quality of the conversation rather than the quality of the audio recording. The host of the interview is a fast talking Irish doctor, a jack of all trades but a master of none, a perpetual student and a trainee of the CICM. The “Jellybean” is an itinerant podcast that regularly appears on www.LifeinTheFastLane.com, www.IntensiveCareNetwork.com and many other websites. Over 100 conversations have been recorded with persons of interest. They will appear on iTunes and Google play once the 100th episode is published later this year.
The CICM ASM Jellybean series each start with a biographical component and then the conversation follows its own path. The subject matter is usually that which dwells upon the fringes of intensive care medicine; human factors, education, ethics, equality, gender, personal histories, possible futures and all the other challenges that we so often face. Being so they compliment the lectures but do not attempt to repeat them. We hope you enjoy finding out a little more about the people behind the CICM Annual Scientific Meeting. The four CICM x Jellybean co-branded recordings are part of a larger collection. It is only these four that are formally associated with the College. Doug Lynch is not a representative of the college and any views expressed are his own.
Associate Professor Charlie Corke
President of the College of Intensive Care Medicine of Australia and New Zealand (CICM).
The CICM is the worlds first stand alone College of Intensive Care Medicine. A/Prof Charlie Corke is the President.
It is not an easy job to do.
It is not an easy job to get. Charlie got there by a path less travelled and he talks about that path, among many other things, in this short interview recorded at the Annual Scientific Meeting of the College.
Each year the CICM holds its Annual Scientific Meeting. The Meeting has always been
focused upon a single issue or organ system. This year the theme was Gastroenterology
entitled “A Gut Reaction; ICU Gastroenterology from beginning to end.”
The lectures presented at the meeting have been recorded and will all be shared among the delegates and some will also be shared with all comers via the Intensive Care Network (www.IntensiveCareNetwork.com), the celebrated “#FOAMed” website. (Free Open Access Medical Education.)
The organisers of the ASM invited #FOAMed podcaster/interviewer Dr Doug Lynch to come along to engage some of the leading lights of the meeting in conversation and record them.
These recordings are the latest in a series of podcasts/blogcasts playfully called “Jellybeans”. They are entirely spontaneous chats with interesting people; short, completely unscripted, 100% unedited and recorded in one take.
It is essentially a live recording. The focus is unapologetically on the quality of the conversation rather than the quality of the audio recording.
The host of the interview is a fast talking Irish doctor, a jack of all trades but a master of none, a perpetual student and a trainee of the CICM.
The “Jellybean” is an itinerant podcast that regularly appears on www.LifeinTheFastLane.com, www.IntensiveCareNetwork.com and many other websites. Over 100 conversations have been recorded with persons of interest. They will appear on iTunes and Google play once the 100th episode is published later this year.
The CICM ASM Jellybean series each start with a biographical component and then the conversation follows its own path. The subject matter is usually that which dwells upon the fringes of intensive care medicine; human factors, education, ethics, equality, gender, personal histories, possible futures and all the other challenges that we so often face. Being so they compliment the lectures but do not attempt to repeat them.
We hope you enjoy finding out a little more about the people behind the CICM Annual Scientific Meeting. The four CICM x Jellybean co-branded recordings are part of a larger collection.
It is only these four that are formally associated with the College.
Doug Lynch is not a representative of the college and any views expressed are his own.
This is the oration John Myburgh gave at the College of Intensive Care's Annual Scientific meeting when he was awarded the College Medal for a career's worth of contributions. This was actually recorded a couple of days after the event by Lily Foster & Oli Flower, but it still contains all the emotions and sentiments that were there on the night when it was delivered at Doltone house on 27th May 2017.
Sarah Yong is an impressive person. Advocacy, Training, Representation and being a new fellow of the College of Intensive Care to boot. Theres a lot to talk about when you sit down with Dr Sarah Yong. Let’s make it easier by focussing on three big issues; Gender issues; Women in Intensive Care Network. Training issues; The Critical Care Collaborative and the Victorian Primary Examination Course for CICM. The Trainee Symposium at CICM ASM. Representation issues; New Fellows Rep on the Board of the College of Intensive Care Medicine. Where to start? The Women in Intensive Care Network or W.I.N.. (or on twitter @WomenIntensive) WIN is co-convened by Sarah and Dr Lucy Modra. Sarah gives all the credit to Lucy. I suspect Lucy might do something equally graceful. If my sources are correct there pretty much the same number of women and men out there in the world. Further it seems that there are roughly the same number of women and men presenting to intensive care units. This pattern does not repeat it self in terms of the Intensive Care doctors. Let’s talk about this. Let’s listen to the people that are raising awareness about this. The Women in Intensive Care are talking about it and publishing about it too. You may have heard about the Medical Journal of Australia article; “Female representation at Australasian specialty conferences”. But they have not stopped proving their point. Next there was “Women in Leadership in Intensive Care Medicine” published in Jean-Louis Vincents open access e-journal “ICU Management and Practice”.
There have been only four presidents of the College of Intensive Care, all male. However the pre-cursor to the College was the Joint Faculty of Intensive Care Medicine (JFICM), which was the body that actually created the college. The first leader of JFICM was the one and only Dr Felicity Hawker. Hopefully soon to be published will be a presentation from the Noosa ANZICS CTG (Australia & New Zealand Intensive Care Society Clinical Trials Group) by Dr Naomi Yarwood about the lack of women in the ANZICS CTG studies over the last 20 years.
Next Issue; Training. After competing her Fellowship exams Sarah got involved in the Critical Care Collaborative and went on to found the Victorian Primary Examination Course for CICM (VPECC). Running that
is a big job in itself. It’s popular too and the July 2017 edition is already full. Sort of. Importantly the candidate stream is full for 2017 but there is a teaching stream too. Have a look at this if you are an aspiring educationalist.
See the Post on Intensivecarenetwork.com
Ash Banerjee talks about the history of ventilation and where we are today. He discusses in particular current concepts about lung protective ventilation strategies and how we can ventilate with the least amount of harm.
For more details on how to select the ideal PEEP for a patient, or how one would set up the ventilator for an ARDS patient, have a look at Alex Yartsev’s site Deranged Physiology, where there’s a great post on the Optimal PEEP for Open Lung Ventilation in ARDS which specifically mentions Gattinoni’s recent review paper.
Cannulation Part 2
by Roger Pye
Welcome to learnECMO podcast series. This instalment is the second part of Roger Pye’s meditations on ECMO cannulation, this time focusing on Avalon, VA and the duplicitous art of backflow cannulation.
On the subject of cannulation, places for SMACCannulate are going fast so head to the SMACC website if you fancy a crack at the title of world fastest cannulator and sign-up. Now we do realise that optimal procedural ergonomics does not prioritise speed and we have had lots of enquiries about actually learning to cannulate. As such we will be offering sessions at the pop-up SMACCannulate station where all comers will be welcome for hands-on cannulation teaching. We will teach you how to finesse and troubleshoot each element of ECMO cannulation from ultrasound guided seldinger technique to mitigating the perceived disaster of a bent wire. Go to the SMACC website to register for either of these sessions.
If you are not able to join us in berlin then we will be co-hosting a cannulation workshop at ST. Thomas’s hospital in London with the GSTT ECMO team, one of the highest volume centres in the world with a highly sophisticated intensivist led ECMO retrieval service. learnECMO London will be on Monday 3rd July and you can register via learnECMO.com, come and learn some high fidelity cannulation chicanery from some proper experts.
Associate Professor Neil Orford is the director of the intensive care unit at University Hospital Geelong. In his time as director he has overseen some major developments within his unit, including the introduction of a paediatric service. Here he shares some of his strategies on what it takes to be an effective leader.
by Steve Morgan & Sophie Connolly
Today we are going to cover the essentials of ECMO haemodynamics. Haemodynamics literally means blood movement and thus is the physical study of flowing blood and the structures through which it flows. In bedside vernacular we tend to use haemodynamics to refer to accessible surrogate measurements of cardiovascular performance, such as vascular and chamber pressures or quantifications of macrocirculatory blood flow.
To understand the haemodynamic effects of ECMO we will consider the effects of the in-parallel VA circuit and the in-series VV circuit separately. The effect on cardiac performance can be best approached and compartmentalised by examining the impact of ECMO on each of the determinants of stroke volume: preload, afterload and contractility.
This podcast covers:
How can we best describe ventricular function and the effect of ECMO?
What factors influence the net effect of VA ECMO on patient haemodynamics?
What are the general primary haemodynamic effects of VA ECMO?
How does cannulation site influence the haemodynamics of VA ECMO?
What do you do about a non-ejecting heart on VA ECMO?
What about the RV? How does the unique functional anatomy and physiology contribute to RV failure?
What are the haemodynamic effects of VA ECMO on the RV?
What are the haemodynamic effects of VV ECMO?
This round table discussion from the JICScast team asks whether Intensivists are the greatest danger to Intensive Care. They tackle why single or dual specialty training is recommended and whether this could endanger Intensive Care as a specialty field. The podcast is inspired and based on a blog post written by Aoife Abbey, trainee in intensive care https://whistlingdixietalk.wordpress.com/2016/11/16/the-biggest-threat-to-icu-intensivists/
Associate Professor Neil Orford is an intensive care specialist and Director of Intensive Care at University Hospital Geelong. Neil is the clinical lead for the i-Validate program. In this podcast he discusses this collaboration between Barwon Health and Deakin University which aims to improve patient-centred end-of-life care through training in clinical communication.
Associate Professor Sue Berney is head of physiotherapy at Austin Health.She has over 20 years experience working in the cardiorespiratory field, with a particular interest in critical care and early rehabilitation. She currently holds an NHMRC Early Career Fellowship and has a passion for research into patient outcomes in intensive care. Here she discuses cognitive dysfunction post critical illness.
Peter Brindley, an intensivist from Canada, and Jon Gatward (of the Critical Care Airway Management Course fame) discuss a recent paper by Peter and a group of airway experts, which discusses airway management outside the operating room and how to better prepare. Clearly this isn't a new concept but there hasn't been much written from the ICU perspective about this, and it's something many of us deal with all the time. Every place has their own way of managing airways but there are so many good ideas in this paper that it might just change your practice!
Kimberley Haines is a senior ICU physiotherapist and the Allied Health Research Lead at Western Health. Her academic research focusses on the long term progress of ICU survivors. Here she discusses the developing puzzle of ICU outcomes.
Professor Andrew Davies is an Intensivist working at Peninsula Health in Melbourne with a special interest in nutrition in the ICU, and is a past Chair of the Australian and New Zealand Society of Parenteral and Enteral Nutrition (AuSPEN). In this talk, Professor Davies tackles the often overlooked aspect of nutrition in the ICU and it’s potential benefits for our patients
Professor Rinaldo Bellomo is an Intensivist at the Austin Hospital in Melbourne. He is Professor of Medicine at Melbourne University, and Honorary Professor of Medicine at Monash University, Melbourne and The University of Sydney.
He is one of the most eminent researchers in Intensive Care Medicine today and has been named one of the most influential scientific minds of our time.
In this thought-provoking talk Professor Bellomo discusses glycemic control of critically ill diabetic patients in the ICU.
Pete McCanny gives a talk on the cutting edge management of cardiogenic shock and challenges the conventional approach to mechanical support.
David Anderson, intensivist at the Alfred, discusses dementia, death and end of life care in the intensive care unit
learnECMO
Roger Pye on cannulation, part 1.
This podcast is the first of 2 parts of the Cannulation 101 session from the recent ECMOcannulate course. It is delivered by a true expert in the form of Roger Pye, erstwhile renal physician, intensivist and cardiac anaesthetist with 10 years of ECMO retrieval experience.
In part 1 Roger gets right down to the grain on VV cannulation and just how vital cannula configuration is to optimising systemic oxygenation, an essential consideration when bundling ECMO patients up for a 4000km aeromedical retrieval.
Look out for part 2 which will cover the Avalon cannula and cannulation for VA ECMO.
Thanks for listening. If you're interested in honing your cannulation skills go to learnECMO.com to register your interest for ECMOcannulate in 2017. We will also be in Berlin at the blue riband crit care conference, das SMACC, where we will invite all comers to set the ECMO cannulation world record.
Stroke thrombolysis - why are we still arguing? Summary by Lachlan Donaldson
The debate regarding the efficacy of thrombolysis grumbles on… How is it that two different groups (i.e. mostly ED doctors and neurologists) can look at the same set of trials and come to fundamentally different conclusions?
To examine this, these authors have attempted to perform an unbiased meta-analysis and systematic appraisal of the evidence supporting the use of thrombolysis in ischaemic stroke (paper available here).
Consistent with other meta-analyses, the authors found a moderately increased probability of good functional outcome (OR 1.14) alongside a markedly increased risk of ICH (OR 4.28).
However, as discussed, this debate is likely to be driven by the quality of the trials that populate this meta-analysis.
For instance, of the 16 studies that nominated a specific primary outcome, only 2 studies reported a significant treatment effect in favour of thrombolysis as their primary outcome- the NINDS trial and ECASS III. Both of these studies have reported concerns baseline imbalance.
Buried in the Supplementary Appendix is also the 'influence analysis' which shows the significant influence of the NINDS and IST-3 trial, both of which have significant methodological limitations.
Transparently analysing this controversial data was not without challenge – most trialists and drug companies were reluctant to share trial data without contracts and editorial influence (notwithstanding stated commitments to data-sharing). Once completed, most journals with broad readership rejected the paper on the basis that there was no ongoing debate; their view was that that the evidence was sound and that replication studies were not warranted.
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Associate Professor Vincent Pellegrino is a Senior Intensive Care Specialist at The Alfred Hospital and head of the ECMO Clinical Service. He has had a lead role in the development of ECMO services at The Alfred since 2003. From the ECMO CPR ICN Victoria meeting he discusses how to get patient selection and outcomes right for eCPR.
Peter McCanny is part of the LearnECMO team. In this podcast he explains some of the background and history of ECMO CPR, what evidence there is to support its use and where we're heading in the future.
Basic Science Clinic by Steve Morgan & Sophie Connolly
In the words of the 3rd greatest physicist of all time, James Clerk Maxwell:
“It is of great advantage to the student of any subject to read the original memoirs on that subject, for science is always most completely assimilated when it is in the nascent state.”
Welcome to Basic Science Clinic Raw Science 10. Not before time we are ready to approach the alveolar-capillary membrane to substantiate the factors that determine the reciprocal exchange of biologically operative respiratory gases. For all the demonstrable complexity of transport and signaling mechanisms in the human body, the energetically neutral transaction of simple passive diffusion is culpable for the cascading maintenance of gas exchange homeostasis and oxidative phosphorylation, with its explosive potential for driving the evolution of ostentatious biological complexity. The adaptive imperative to exploit diffusion for gas exchange imposes certain anatomical demands on the respiratory system. Namely the requirement for a huge tissue surface area of negligible thickness, and minimising diffusion impedance, whilst ensuring dependable partitioning of air space and blood compartments, even in conditions of extreme flow and pressure fluctuations. In this pod we will detail the determinants of diffusion and unravel its antecedence to the segregation of the pulmonary and systemic circulations as a prelude to dissecting the emblematic features of pulmonary perfusion.
In this podcast:
What is Graham’s Law?
How does diffusion proceed in the human lung?
So where does Fick’s law fit in?
What is meant by diffusion and perfusion limitation?
How do we quantify pulmonary diffusion?
What are the physiological components of the diffusing capacity?
How is diffusion responsible for the pulmonary circulation?
Here are some Raw Science factoids:
As barometric pressure reduces linearly with altitude, it reaches 30% of that at sea level when entering the death zone at 8000m, which coincident with an inspired oxygen partial pressure of only 48 mmHg and life-threatening diffusion limitation.
Breathing carbon monoxide at a fractional concentration of 0.0128, 1.28% or 12800ppm leads to unconsciousness in 2-3 breaths and death in under 3 minutes.
Selective breeding of elite racehorses means they can generate pulmonary capillary pressures of the order of 100 mmHg during galloping, leading to near ubiquitous stress failure and varying degrees of exercise-induced pulmonary haemorrhage.
For feedback, corrections and suggestions find us on the twitter handles @falconzao and @sophmconnolly or alternatively post on ICN. Also check out our website basicscienceclinic.com.
Thanks for listening. Next up we’ll perform a detailed public vivisection of the pulmonary circulation.
ECMO Gas Exchange by Steve Morgan & Sophie Connolly
This is the first in a series of ECMO podcast from the LearnECMO team - starting with the physiology of ECMO gas exchange.
Professor Stephen Bernard is an Intensive Care Physician at The Alfred Hospital and Medical Advisor to Ambulance Victoria. His research interests include the use of therapeutic hypothermia for the treatment of neurological injury after resuscitation from out-of hospital cardiac arrest. Here he provides a presentation on recent advances in the management of refractory cardiac arrest in the out of hospital setting.
Jason Maclure is deputy director of Intensive Care at the Alfred Melbourne. He has strong interests in analgesia and sedation, respiratory failure, ventilation, HFOV and ECMO. From an ICN Victoria 2016 meeting on ECMO CPR he discusses the development of the eCPR protocol at the Alfred.
Huy Tran is a lab and clinical haematologist at Peninsula Health. He has research interests in haemostasis and thrombosis and is a member of the Australasian committee for anticoagulation reversal. This is his presentation from an ICN Victoria meeting where he discusses the new oral anticoagulants and what can be done when they cause critical bleeding
Dr Sachin Gupta is an intensivist at Peninsula Health with interests including medical education and quality assurance. In this podcast from an ICN Victoria meeting he discusses the difficulties we currently face in predicting bleeding and how this might change in the future.
The role of Liver Replacement Therapies remains undefined. In this podcast, Associate Professor Luke Torre shares his experience and the science and evidence behind Extra-Corporeal Liver Assist Devices (ELAD) Dr Torre is currently working as an Intensivist/Anaesthetist in Perth, Western Australia. This presentation was originally presented at an ICN WA meeting held 2nd December 2015 in conjunction with Hazeldine on Alcoholic Liver Disease.
Basic Science Clinic by Steve Morgan & Sophie Connolly
In the words of the canonical Roman poet Ovid: “Sickness seizes the body from bad ventilation”.
Welcome to Basic Science Clinic Raw Science 9. Convective gas flow provides the substrate to interface with alveolar structural and functional adaptation in orchestrating gas exchange. Gas exchange is the serial interconnection of ventilation, diffusion and perfusion. Alveolar gas composition is determined by amount and type of gases delivered by ventilation, the rate and direction of gas diffusion, and the pulmonary blood flow which continuously recalibrates partial pressure gradients to direct oxygen and carbon dioxide movement. Bulk gas volume displacement is the mechanism of ventilation, but how do we conceptualise and quantify its contribution to gas exchange and its associated abnormalities? In this pod we will examine the quantification of ventilation and parse its correspondence with variance in the dead space volume and central role in carbon dioxide homeostasis.
In this podcast we will cover:
How do we define pulmonary ventilation?
What is the relationship between alveolar minute ventilation and alveolar gas composition?
What are the determinants of arterial carbon dioxide partial pressure?
What are the physiological sequelae of hypercapnia?
What is permissive hypercarpnia?
What is dead space?
How do we quantify dead space volume?
What are the factors that affect dead space?
Here are your Raw Science factoids:
Morphological dead space estimates give us volumes of 150mls for dogs, 380mls for cows and 150-300L for whales.
In 1986 in Cameroon a paroxysmal expulsion of carbon dioxide from the volcanic lake Nyos resulted in the asphyxiation of 1700 people and 8000 animals.
The highest documented PaCO2 to be measured in a subsequent survivor weighed in at 501 mmHg in a 16 year old boy swallowed, sequestered and asphyxiated by a rapidly filling grain truck.
For feedback, corrections and suggestions find us on the twitter handles @falconzao and @sophmconnolly or alternatively post on ICN. Check out our new website basicscienceclinic.com where you can access the back catalogue and peruse the real brains behind our elaborate plagiarism by checking out the reference page to go direct to the source material.
Thanks for listening. Next up we’ll consummate the journey of inspirate atmospheric gas into the blood phase, as we appraise gas diffusion across the alveolar-capillary membrane and dissect the pulmonary vasculature.
Pulmonary Hypertension and Right Heart Failure remains elusive and challenging to even the seasoned Intensivist. In this post, Playford unravels the mysteries behind Right Heart Failure and ECHO tips and pitfalls.
Originally recorded 28th July 2015 at the Inaugural ICN WA meeting
Professor Playford is a Cardiologist with a special interest in pulmonary hypertension and has recently authored a chapter in Otto's "The Clinical Practice of Echocardiography"
Claire Cattigan is an Intensivist and Deputy Director of ICU at The University Hospital Geelong. She is interested in the management of paediatric patients in mixed ICUs and gives a fascinating talk on the challenges and rewards of introducing paediatric patient care into a general, adult intensive care unit.
The decision to admit patients with Alcoholic Liver Disease to ICU is polarising. In this podcast, Dr Simon Hazeldine uncovers the evidence behind outcomes and management of these patients and why these patients should be considered for therapy in the ICU.
In this podcast, Mr Larbalestier shares his experiences with cardiac transplantation and guides us through some his POV footage of the first heart transplantation at the new Fiona Stanley Hospital.
Ciaran McKenna and Andy Buck have a pow-wow with Matthew Mac Partlin on 3D Printing - Where it's up to, where it might go and how they are using it.
Dr Steve McGloughlin is an intensivist at the Alfred Hospital. He has a special interest in education particularly the use of simulation and crisis resource management skills in critical care. He is also an infectious diseases specialist and maintains both clinical and research interests in infections in critically ill patients. Here he discusses the ongoing primacy of antibiotics in intensive care and our continuing battle with antibiotic resistance
Professor Cornely is Professor of Internal Medicine and Director for Clinical Trials at University Hospital, Cologne, Germany. His research interests include invasive fungal diseases in haematology/oncology and in the ICU setting. Here he discusses the epidemiology, diagnostic challenges, appropriate prophylaxis and treatment of fungal infections in the ICU with a focus on haematology patients.
Irma Bilgrami gives an insightful and engaging talk on mentorship, the mentor and mentee roles and how to ensure everyone has equal access to these important relationships. This was recorded at the May 2016 Women in Intensive Care Network (WIN) meeting in Victoria.
Professor Theodore "Jack" Iwashyna presents an entertaining and informative talk on randomised controlled trials, how we could be getting more useful and better data, and strategies for getting the most out of RCT data in the future. This was recorded at the December 2015 ICN Victoria educational meeting.
Basic Science Clinic by Steve Morgan & Sophie Connolly
An expert is a person who has made all the mistakes that can be made in a very narrow field.
Niels Bohr
Welcome to Basic Science Clinic Raw Science 8. Convective gas flow through the tracheobronchial tree is the end-point of pulmonary mechanics but the fundamental purpose of the lung is gas exchange, comprised of three interlinked physiological processes: ventilation, diffusion and perfusion. Today we examine the incredible structural adaptation of the human lung down to the alveolus as the centrepoint of gas exchange, a process itself best conceptualized via the elegant physiological model of the alveolar gas equation.
The unraveling of the procession of pulmonary blood flow from right ventricle to lung to facilitate the mingling of blood and air involved protagonists that spanned epochs from Hippocrates to Galen and eventually in 1661 to Marcello Malpighi. He was the first person to view the pulmonary capillaries and alveoli through the augmented reality offered by the light microscope that had been invented in 1590.
The composition of gas in the alveoli determines and represents the process of pulmonary gas exchange and provides a framework for understanding the mechanisms and practical physiological limitations. Alveolar gas is practically inaccessible in vivo and hence requires an accurate and precise model to ascertain its configuration under specific conditions.
The alveolar gas equation relates the alveolar partial pressure of oxygen to inspired partial pressure of oxygen, alveolar and hence arterial partial pressure of carbon dioxide and the respiratory quotient.
How is the lung adapted to optimise gas exchange?
So how does the alveolus fit in?
What are the cell populations in the alveolar region?
How can we model pulmonary gas exchange?
Raw Science factoids:
The oxygen content of arterial blood is ~21 mls/dl, ie 21% by volume. The oxygen content of mixed venous blood is 15-16 mls/dl indicating a total body oxygen extraction of 25%.
The total alveolar surface area is approximately 80x greater than the total surface area of the skin.
Each erythrocyte contains approximately 250 million haemoglobin molecules and 400 billion erythrocytes occupy the total pulmonary capillary blood volume.
For feedback, corrections and suggestions find us on twitter @falconzao and @sophmconnolly or post on ICN.
Thanks for listening. Next up we’ll continue our examination of pulmonary gas exchange by looking in more detail at ventilation, perfusion and diffusion. Coming soon is our video series Raw Focus to delve deeper into the key concepts from each of the podcasts.
Basic Science Clinic by Steve Morgan & Sophie Connolly
What we know is not much. What we do not know is immense.
Pierre-Simon Laplace
Welcome to Basic Science Clinic Raw Science 7. As a prelude to deconstructing gas exchange we have been examining how humans, as tidal ventilators, replenish the composition of the gas in the functional residual capacity to provide a plentiful oxygen repository to buffer fluctuations in the oxygen content of blood leaving the lung with every beat of the heart.
Convective, pressure gradient driven, bulk gas volume displacement can only occur if the displacing force is greater than the forces that oppose gas flow. These oppositional forces are the physiological targets of pathological processes that affect the lung, that alter pulmonary mechanics, increase work of breathing eventually critically compromising respiratory function and indicating the need for respiratory support measures. To effectively manage organ system dysfunction it is vital to develop an intimate understanding of your enemy so today we will examine the oppositional forces to gas flow that are among the key perpetrators of respiratory failure.
In this pod we’ll cover:
What are the oppositional forces to gas flow?
What is elastance?
What is elastic recoil and what are its determinants?
How does the lung prevent surface tension induced alveolar instability?
What is the 2nd major oppositional force to gas flow?
How do these driving and oppositional forces relate to work of breathing?
Raw Science Factoids
During inspiration the alveolar radius increases from 0.05mm to 1mm which should require a distending pressure of 10 cmH2O but surfactant’s detergent action means that 1 cmH2O will suffice.
Normal resting VO2 is approximately 2-4 mls/kg/min. In terms of VO2max an average untrained healthy male would approximate 35-40 ml/kg/min and former multiple Tour de France champion and King of the Mountains Miguel Indurain hit 88ml/kg/min at his peak. Racing Siberian sled dogs can reach 240 ml/kg/min.
Elite rowers can escalate their total minute ventilation to 240 L/min by hitting respiratory rates of 60/min and tidal volumes of 4000 mls and inspite of this heroic effort still generate lactates of 15-18 mmol/L.
For feedback, corrections and suggestions find us on twitter @falconzao and @sophmconnolly or post on ICN.
Thanks for listening. Next up we’ll begin our examination of pulmonary gas exchange, also coming soon is the second Crit Think series, Doors of Deception, in which we will look at the labyrinthine and mendacious ways our decision making faculties can deceive us.
Burns Microbiology by Janin
Infection is a major cause of morbidity & mortality in burns. Pierre goes through the common bugs responsible and how to manage them.
Jon Gatward goes through everything you need to know about approaching the airway of a patient with burns.
Basic Science Clinic by Steve Morgan & Sophie Connolly
Although this may seem a paradox, all exact science is dominated by the idea of approximation.
Bertrand Russell
Welcome to Basic Science Clinic. This is Crit Think episode 6, the final podcast in our mathematics series in which we will discuss the mathematics behind clinical measurement.
The use of ever advancing technologies is an inherent and necessary component of critical care, encompassing the most basic of measurement devices (the sphygmomanometer, the stethoscope) to the most complex methods of organ support. Such devices enable continuous monitoring and measurement of physiological variables, informing decision-making processes and underpinning management choices.
Unfortunately, the fallibilities of the clinical process extend far beyond that of human error, and increasingly so, as technological developments entail greater reliance on medical devices. Along with this, comes the tendency to overplay the perceived accuracy and precision of such devices, permitting clinical judgment to be overshadowed or misled by numerical outputs.
Accuracy and precision are terms that are colloquially interchanged, but in truth carry different meanings and different implications for specific features of the variables they are describing. While we strive for accuracy, precision represents our chance of reliably achieving it.
In this pod we’ll cover:
- Accuracy and precision
- Signal to noise ratio
- Zeroing and calibration
- Fourier analysis
Without language, thought is a vague, uncharted nebula
Ferdinand De Saussure
Word of the day: sententious (adjective). Given to moralizing in a pompous or affected manner.
For feedback, corrections and suggestions you can contact us on our twitter handles @falconzao and @sophmconnolly or post on the Intensive Care Network.
This talk covers burns assessment and initial wound management, including the types of dressings available. Very easy to get wrong, with serious ramifications if you do!
Burns Resuscitation.
Lewis Macken takes us through the initial 24 hours of managing a patient with significant burns. Lewis tackles the tricky questions of how much and what kind of fluid to give, and explains the history behind burns resuscitation.
Basic Science Clinic by Steve Morgan & Sophie Connolly
If you can’t explain it simply, you do not understand it well enough.
Albert Einstein
Welcome to Basic Science Clinic Raw Science episode 6. The next step on the oxygen cascade relates to the composition of alveolar gas, how and why it differs from that in the upper respiratory tract and conducting airways. This composition is determined by the components of the alveolar gas equation. We will examine the AGE in more detail in the next podcast, but for now we can take it to be PAO2 = PiO2 – PaCO2/RQ. In this conceptual model the PiO2 describes the gas entering the alveolus and the second half, the minus PaCO2/RQ, is the net gas leaving the alveolus as oxygen is exchanged with CO2 across the alveolar capillary membrane. The PAO2 is therefore the net alveolar oxygen partial pressure reflecting the interaction of these two processes. The composition of PiO2 we ascertained in the last podcast where humidification and warming of inspiratory gas at 1 atm leaves us with ~150 mmHg of oxygen partial pressure at the carina. Before we analyse the gas in the alveolus we are going to examine how it gets there and the factors that affect pulmonary ventilation and respiratory gas flow.
Remember deranged physiology at each transition point on the oxygen cascade may limit the efficacy of oxygen transfer and hence reduce the amount of oxygen delivered to the mitochondria. It is important to understand the ways in which these steps can be disrupted and then systematically consider them all in your assessment of undifferentiated hypoxia. Step 1 is calculating the PiO2, which is FiO2 multiplied by Patm – PH2O. Therefore reduced FiO2, for example when oxygen is consumed in a house fire, or reduced barometric pressure, for example on the peak of mount Everest, are both potential causes in reduced oxygen partial pressure at step 1 and hence are causes of downstream tissue hypoxia.
For step 2 a comprehensive understanding of the complex of interrelated factors that affect respiratory gas flow and the provision of oxygen replete inspired gas to the alveolus is crucial core knowledge for a budding critical care physician. To bear the responsibility of mechanically ventilating a patient’s potentially injured lung, it is incumbent on us to be fortified by a high fidelity conceptual model.
In this pod we will cover:
Fluids and Flow
How can you predict the type of flow in a fluid system?
How do you define viscosity?
What about the specifics of gas flow in the airways?
What is ventilation?
So how does the respiratory apparatus generate a pressure differential?
Raw Science Factoids
The total length of the airways running through the two lungs is 1,500 miles or 2,400 kilometers.
The 300-500 million alveoli produce a combined surface area of 50-100 m2, a size roughly equivalent to a tennis court.
The relatively high oxygen content of air means we would only have to breathe once per minute to meet the body’s demand for oxygen at rest, the bulk of ventilatory work is for the elimination of carbon dioxide.
For feedback, corrections and suggestions find us on twitter @falconzao and @sophmcon or post on ICN.
Thanks for listening. Next up we’ll examine the oppositional forces of respiratory gas flow and the work of breathing.
Effective patient management requires a combination of timely diagnosis, appropriate medical management and application of human factors. Human factors is the study and application of human interaction with the systems around them. It combines engineering and psychology, and a recognition that humans are not machines and subsequently make mistakes. In order for a system to be robust, it needs to take these factors into account.
In other industries, the role of human factors in developing a robust safety culture is well-established. Human factors and non-technical skills are increasingly recognised as a cornerstone of effective management in high stress situations where critical decisions are being made. Nowhere is this more applicable than within critical care.
Closely allied to human factors are non-technical skills. These comprise Communication, Teamwork, Leadership and Situational Awareness - of which Communication is generally regarded as the most vital. These four aspects are vital for effective patient care, particularly in a critical situation. However, for a number of reasons they can become easily compromised - at exactly the time when you need them most. If one fails, there can often be a loss of the other aspects, for example a loss of Situational Awareness in a high-stress situation can result in a failure of Communication, and thus Teamwork. All this can result in poor patient care, or even patient harm.
Using a number of examples, this Podcast discusses some learning points that we can take from both other industries as well as cases of medical error. Strategies to improve the systems we work in are discussed, many of which are now common place in the workplace such as checklists, protocols, standardisation and forcing functions.
Basic Science Clinic by Steve Morgan & Sophie Connolly So mathematical truth prefers simple words since the language of truth is itself simple.
Tycho Brahe
Welcome to Basic Science Clinic, this is Crit think episode 5. Today our exploration of the mathematical architecture of our most inexact of sciences brings us upon the edifice of logarithms and exponentials. Daunting as it may sound, we will try to tease out their utility and relevance to critical care medicine and even attempt to penetrate the secrets of the mysterious number e.
Logarithmic transformations permeate pharmacokinetic, biological and physiological modelling. Exponentials are the inverse function of the logarithm, and the special properties of explosive exponential change in quantities has implications for ventilation, pharmacotherapy and beyond.
Euler’s number, e, represents the idea that all continually growing systems are scaled versions of a common rate. Describing e as a constant approximating 2.718 is like calling pi an irrational number approximating 3.141. It’s true but it totally misses the point. Pi is the ratio between the circumference and diameter of every circle. It is a fundamental ratio and therefore impacts any calculation involving circumference, area, volume and surface area for all circles, spheres and cylinders. e is not just a number it is about the fundamental relationship between all growth rates.
Thanks for listening. From The Happy Prince by Oscar Wilde: “I am so clever that sometimes I do not understand a single word of what I am saying.”
Word of the day: evanescent
Literary: soon passing out of sight, memory, or existence; quickly fading or disappearing.
Physics: denoting a field or wave which extends into a region where it cannot propagate and whose amplitude therefore decreases with distance.
For feedback, corrections and suggestions you can contact us on the twitter handles @falconzao and @sophmconnolly or post on Intensive Care Network.
Next up is the last in this Crit Think: You Do the Math(s) series and we will examine the mathematics behind clinical measurement.
Dr Andrew Davies, Intensivist at Frankston Hospital in Melbourne discusses how Intensive Care Specialists can better care for themselves, including avoiding burnout, eating well, exercising, escaping work, and meditation. This talk was recorded at the ICN Victoria meeting in December 2015.
Basic Science Clinic by Steve Morgan & Sophie Connolly
“…water is the driving force of all nature….without it, nothing retains its form.”
Leonardo Da Vinci
Welcome to Basic Science Clinic Raw Science episode 5. Let’s get down to business and accompany oxygen on its relentless tumble from nasopharynx to mitochondria down the partial pressure staircase that explains how 160 mmHg of inspired oxygen partial pressure becomes 20 mmHg in the inner mitochondrial matrix. In this pod we will examine step one of this cascade and the science of the humidification of dry, inspired atmospheric gas, whilst paying deference to dihydrogen oxide.
Water is pretty amazing stuff. It is the solvent of life characterized by anomalous idiosyncrasies without which biology wouldn’t even be a thing. It is the only substance found concurrently in 3 phases on Earth’s surface and is a byproduct of the outpouring of stellar gas and dust produced when a star is born. NASA recently discovered a water vapour cloud surrounding a quasar 12 billion light years away, a celestial snapshot capturing the antiquity of water in the universe.
What to expect:
- What makes water so special?
- What is water’s role in the first step of the oxygen cascade?
- What is the difference between a gas and a vapour?
- How do you define humidity?
Raw Science Factoids
The length of the side of a cube that could hold all of Earth’s water is 1150 km, containing 1.5 billion km3 or 800 trillion Olympic swimming pools.
Everywhere there is liquid water on Earth there is life inspite of temperatures of 100s of degrees or searing acidity.
All of Earth’s water likely arrived on carbonaceous meteorites that can be up to 20% water as ice, between 4.5-3.8 billion years ago during the late heavy bombardment.
Thanks for listening. For feedback, corrections and suggestions find us on twitter @falconzao and @sophmcon or post on ICN. Next up we’ll scrutinize respiratory gas flow.
Basic Science Clinic by Steve Morgan & Sophie Connolly “Isaac Newton was not the first of the age of reason. He was the last of the magicians.”
John Maynard Keynes
Welcome to Basic Science Clinic, Crit Think episode 4, in which we will discuss The Calculus. One of the crowning intellectual achievements of humanity, Calculus is the foundational mathematical concept of modern science. Almost usurped by a publication entitled the Complete History of Fishes released only months earlier, through his development of the fundamental theorem, Newton (or was it Leibniz?) has provided us with the tools to successfully land a rover on the surface of Mars.
Calculus delineates the dynamic system. It is the lens through which we may focus our perception of bedside numbers and observations to comprehend the beat to beat physiology of the critically unwell.
In this pod we’ll cover:
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Newton and Leibniz and the development of the fundamental theorem of calculus
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Differentiation and pressure-volume relationships
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Integration and area under the curve
Word of the day:
Propinquity: the physical or psychological proximity between people.
Basic Science Clinic by Steve Morgan & Sophie Connolly
We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science and technology.
Carl Sagan
Welcome to Basic Science Clinic Raw Science episode 4. We are close to embarking on the descent down the oxygen cascade, en route we will examine the key contributors to these stepwise decrements in oxygen partial pressure that coax the gas down to the level of the mitochondria. To grasp the concepts essential to the physiology of this pathway you need to understand the fundamentals of gas behaviour, enter the gas laws.
In this pod we will cover:
Boyle’s, Charles’, Guy-lussac’s laws
Avogadro’s number
Dalton’s and Henry’s laws
Saturated vapour pressure & boiling point
The concept of in vivo partial pressures
Raw Science Factoids
Increasing ambient pressure from 1 to 2 atm will decrease the volume of 1L water by <0.01% and decrease the volume of 1L air by 50%.
At an oceanic depth of 40m an FiO2 0.21 results in a PiO2 > 400 mmHg and FiO2 1.0 gives PiO2 > 2000 mmHg, resulting in tissue hyperoxia.
Opening a soda can drops the pressure of the CO2 gas above the liquid that has set up an equilibrium in accordance with Henry’s law. This results in CO2 rushing out of solution to reach a new equilibrium with ambient, atmospheric CO2 partial pressure.
Basic Science Clinic by Steve Morgan & Sophie Connolly
If you would be a real seeker after truth, you must at least once in your life doubt, as far as possible, all things.
Rene Descartes
Welcome to Basic Science Clinic, this is the 3rd Crit Think podcast on mathematics. Having examined the origin of maths and its influence on the enlightenment explosion of rationality and empiricism, we now turn our attention to extracting the ways maths turns up in our critical care practice.
Is it essential to know the maths? Thou doth protest too much methinks. Think of these relationships as the grammatical fibre to your conceptual fabric. It’s like totally, you know like, easy to make yourself understood without no grammar, do ya know wanna I mean…like? However, understanding maths as the language of science with grammatical and linguistic accuracy changes your perception of the relationships between the physiological variables that you are attempting to dial up in your practice. Go deeper, understand better, effortlessly recall.
In this pod we’ll cover:
Basic mathematical relationships
Relations Vs Functions
Classification of mathematical models
Important relations in critical care
Word of the Day: Peripatetic; 1. adjective; itinerant, walking or traveling about; 2. noun; an adherent of Aristotelianism.
Basic Science Clinic by Steve Morgan & Sophie Connolly Equipped with his five senses, man explores the universe around him and calls the adventure Science.
– Edwin Hubble
Welcome to the third podcast in the Basic Science Clinic Raw Science series. Following our investigation ofthe how and why of oxygen, you may be eagerly anticipating the gas’ entry into the respiratory system, prompting a discussion of gas flow, partial pressures and similarly patient-based physiology. Think again. Resisting the urge to dive down the trachea, we need to describe some foundational concepts to fine tune the resolution of your understanding. Enter atmospheric physics. Remember physiology is functional biology, biology is effectively applied chemistry, and chemistry is applied physics.
This week we discuss the physics of atmospheric gas in the biosphere. Such a topic raises discussion of fluid and gauge pressure, heat and temperature, the SI units and clearly, why the sky is blue.
Feedback, requests and corrections are always welcome.
Raw Science Factoids
- The atmosphere has a total mass of 5 x 1018kg, or 5 quintillion kg or 5 zettagrams (1021), which is 5 sextillion grams.
- Every square metre of Earth has 10 tonnes of atmosphere pressing down on it.
- The average temperature of the universe is 2.73K, which is -270.42°C.
Basic Science Clinic by Steve Morgan & Sophie Connolly
“As far as the laws of mathematics refer to reality, they are not certain; and as far as they are certain they do not refer to reality.”
- Albert Einstein
Welcome to the second podcast in the Crit Think series from the Basic Science Clinic. Remember, this is about stimulating insights into the machinations of your mind to assist able deployment of the knowledge you are rapidly assembling, to be a better scientist. Having discussed the evolution of mathematics and the concept of number in our first podcast, we move now to examine the relationship of maths and science. The debatable definition of maths as a science is one thing, but its contribution to science in its performance and explication, and also in informing the development of the method itself, is unquestionable and worthy of acknowledgement.
Addressing a subject that entire degrees are dedicated to escaped the confines of our usual length, but we hope you can hang in there with us. Continuing our trend of celebrating the inner geek, we couldn't resist delving deep into the mathematical origins and historical path of the scientific method to illuminate the intellectual inventory of evidence based medicine as we use it today. Thanks for coming back for more.
In this pod we’ll cover:
- What is science and does maths qualify?
- What is the scientific method?
- How did the method develop and where does maths fit in?
Word of the Day: Pulchritudinous: Having great physical beauty.
Basic Science Clinic by Steve Morgan
Among the notable things about fire is that it also requires oxygen to burn - exactly like its enemy, life. Thereby are life and flames so often compared.
- Otto Weininger
Welcome to the second podcast in the Basic Science Clinic Raw Science series. In our somewhat circuitous exploration of respiratory physiology we will complete the story of the promiscuously electronegative pharmaceutical gas oxygen.
In the first episode of this series we addressed the ‘why’ of oxygen, exploring its unique physicochemical properties to explain its onerous position as the foundational slab of our hierarchy of needs. Having traced our way from the presence of oxygen in the atmosphere to the ETC at a mitochondrial level, we now move to the ‘how’ of oxygen. In this second podcast we return to the atmosphere, examining the contributors to the gaseous composition, as both a signature and supporter of complex biology, and the morphological adaptations necessary to successfully interface with the atmosphere to harvest its oxygen content.
As always, we would love to hear feedback/corrections and are happy take requests for content of future podcasts.
Raw Science Factoids
- The size and consequent gravitational force of the inner rocky planets imposes relatively low escape velocities (on Earth it’s 11 km/s) meaning they are unable to retain the abundant, light elemental gases hydrogen and helium. Venus and the Earth are nearly the same size while Mars is less than half the size of Earth. Venus and Mars have atmospheres dominated by CO2. Earth, uniquely in our solar system, retains an atmosphere composed predominantly of N2 and O2.
- Earth formed 4.6 billion years ago from the gravitational accretion of a broiling mixture of interstellar gases and dust. At this stage it had almost no atmosphere and the surface was molten. As Earth cooled, an atmosphere formed mainly from gases spewed forth from active volcanoes.
- 7 billion years ago, blue-green cyanobacteria flourished in the Earth’s oceans. They made gaseous, or free, oxygen by the photolysis of water, utilising the abundant energy source of ubiquitous UV light.
- Until about 430 million years ago, most aerobic organisms lived in the ocean and exploiting oxygen dissolved in seawater. Terrestrial life then appears in the form of small plants and invertebrates that had evolved the ability to harness oxygen in the gas phase directly from the atmosphere.
Basic Science Clinic by Steve Morgan & Sophie Connolly
All our knowledge begins with the senses, proceeds then to the understanding, and ends with reason. There is nothing higher than reason.
Immanuel Kant
Welcome to Basic Science Clinic Crit Think. Our Raw Science series is to provide content for the new programs that you are writing for your intracranial wet-wear, Crit Think is the upgrade of your operating system. The study and understanding of the process, structure and potential pitfalls of thought, ie thinking about thinking or metacognition, helps you to integrate the knowledge you are acquiring and then apply it with scientific rigor, making you a safer, skeptical, rational bedside empiricist. Create the good habits of data seeking and analytics to emulate the best consultants, with their granular, high fidelity knowledge and their near preternatural ability of pattern recognition that leads to the right intervention just in a nick of time.
This series will include mathematics, what latin is to language, maths is to science. Without maths there is no science; and go on to cover: logic, reasoning and logical fallacies; the art of clinical decision making, heuristics, cognitive biases; educational theory; introduction to ethical principles. In the informational age, with ready available knowledge on the end of a digital swipe, there is an even greater imperative that in your nascent development as a clinician you consider these key components of the structure of your most potent, yet potentially deceptive tool, for knowledge application and making critical decisions over seconds to minutes that may be life-saving.
Basic Science Clinic by Steve Morgan
Assume nothing, trust no one, give oxygen.
– Anon
Welcome to Basic Science Clinic Raw Science podcast series. In case you haven’t being paying attention, science is cool. Indulge your inner geek by joining us on our pursuit of developing an integrated scientific understanding from which you can develop a clinical practice informed by deeper insights and inoculation against magical thinking.
We are going to take an unashamedly convoluted journey from atmospheric gas to the mitochondria and back again, to examine respiratory physiology and hopefully frame the information in a format that helps you on your inexorable march to examination success.
Have you ever asked yourself what is all the fuss about oxygen? In the first two podcasts we are going to address why oxygen is the foundational slab of our hierarchy of needs and how it got here in the first place. It might just give you a renewed appreciation of nature’s most vital pharmaceutical.
We would love to hear feedback and we will even take requests from the floor for future subjects. Apologies for any mistakes, we are always happy to learn so corrections are most welcome.
**Raw Science Factoids
- 2 x 1026 molecules of ATP formed daily, or ~160kg from 2500 calories.
- At any one time there is 50g of ATP in the body, cells contain ~1 billion ATP molecules, utilize 2 million ATP/s, regenerating ~600 ATP/s.
- On average we breath ~400 L O2/day and at rest consume ~350 L O2/day.
- Oxygen is the third most abundant element in the universe, and the most abundant by mass in the Earth’s biosphere.
- Increased solubility is evidenced by the increased density of life in the polar oceans.
Paul Young is the man of the moment.
In one week has has published the SPLIT trial in JAMA, the HEAT trail in the NEJM and presented both at the ESICM conference. Platform Trials.
In this interview Paul discusses The SPLIT Trial - the first trial to substantially look at buffered crystalloids vrs saline and now really paves the way for a definitive trial in this area.
He answers some questions that have been asked such as was the volume of fluid sufficient to demonstrate an effect, why PlasmaLyte was used and what he’ll be doing following these results.
HEAT is a much anticipated trial looking at the effect of early administration of acetaminophen to treat fever due to probable infection. This intervention did not affect the number of ICU-free days. Paul captured out imagination on this topic with a talk at SMACC in 2013 and now the dialogue really begins. We discuss where to go from here on this topic that often stimulates passionate debate…
Finally we discuss Platform trials and how they will save the world. This was topic of a talk Paul gave in Chicago which will be released soon. Read this fascinating paper by Berry Connor and Lewis for a real insight into the hot topic.
Grace Leo shares her cornerstones for developing a powerful presentation: passion, purpose and practice. In this workshop talk from smaccGOLD, she also provides tips and strategies to turn an average presentation into one with style. For the full post, please see www.intensivecarenetwork.com
A personal story of cyclone Yasi
The beginning of 2011 was an extraordinary period for natural disasters in our part of the world. It began with the floods in South East Queensland, then Cyclone Yasi, the Christchurch earthquake and finally the Japanese tsunami.
The evacuation of the Cairns Hospital in less than 24 hours is one of the great success stories for Emergency Services in Queensland. It is even more extra-ordinary when one realizes there was no formal evacuation plan for Cairns Hospital in place. Many health professionals put aside their personal welfare and concerns for their own homes to ensure that 320 patients were evacuated without a single fatality. Special mention should be made of those that weathered the Category 5 winds (over 250 km/hr) in the stand-alone basketball stadium that served as the ‘hospital’ for 250,000 people post Cairns Hospital shutting down.
This presentation by Dr Sean McManus outlines an exhausting 96 hours. Firstly managing the evacuation of ten ventilated patients from the Cairns Intensive Care Unit, then packing up his house and bunkering down for the storm and then finally dealing with a critically unwell 5 month old with complex cardiac pathology.
“Polepole”, the Swahili motto for climbing Kilimanjaro is a consistent theme throughout the presentation. Translated as ‘steady, steady’, it means just keep taking little steps until you reach the summit and don’t let the enormity of the mountain overwhelm you.
Bloody Oral Anticoagulants – BCC talk 2014
The use of the New Oral Anticoagulant Drugs present unique challenges for the Intensive Care practitioner
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The NOACs now have PBS approval for non-valvular AF, below knee DVT, DVT prophylaxis and low volume PE
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There is no specific antidote for NOAC related bleeding but don’t despair there are some things that can help
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Routine coagulation testing does not reflect drug levels or anticoagulation activity
Global sales of Dabigatran topped $1billion in 2012.
This talk outlines the pharmacodynamics and pharmacokinetics of the NOACs. Limitations and cautions of use are outlined with a review of the extensive literature. Clinical cases involving the NOACs are presented. The timing of stopping the agents before minor or major surgery, the approach to a patient with intracranial haemorrhage taking oral anticoagulants and the challenges faced when patients have an Acute Kidney Injury whilst taking these
Neurotrauma – How to Put Humpty together again
Humpty is a 23 year old egg, who fancied himself as a bit of a Hipster. Little did poor old Humpty know that his day was about to end in tears and he was to join the 1000 other Australians who annually have a severe head injury.
The talk focuses on Traumatic Brain Injury. There is particular emphasis on Traumatic Subarachnoid Haemorrhage and Transfusion Thresholds in Traumatic Brain Injury.
The discussion explores the incidence and patterns of vasospasm following tSAH and the role, if any, of nimodipine and other therapies usually reserved for the aneurysm SAH population
The optimal target haemoglobin concentration following TBI is unknown. The discussion looks at the literature and explores the pathophysiology of anaemia in this setting. A blood conservation strategy for patients with TBI is outlined
Penetrating injuries to the neck is a great summary of how to assess and manage neck wounds from lacerations to the airway to gunshot wounds. The talk covers relevant anatomy, the zones of the neck and how to investigate vascular, tracheal and oesophageal injuries. A comprehensive understanding of the relevat anatomy is essential to recognising associated injury patterns. The improvements in the accuracy of helical CTA scans has meant that the delineation of the zones of the neck has become less relevant to the further investigation and management of pemetrating neck wounds. Oesphageal injuries remain difficult to detect and require a high level of clinical suspicion to identify these.
Feeding in the Intensive Care - A trickle or a torrent, is a great summary of several key critical care nutrition trials and how we can apply the evidence from these to the ICU patient. Providing adequate nutrition to patients in the intensive care is an extremely complex therapy that must be carefully titrated on a daily basis. The evidence for how to provide nutrition to critically ill patients is largely lacking and what evidence there is is often contradictory. In this presentation I will look at four feeding trials conducted in the ICU setting and published over the last 3 years. While the results are somewhat conflicting, there are lessons from each that we can apply at the bedside.
SMACC BACK! with Dr Kevin Fong
An interview with Kevin Fong following his talk on safety lessons from space at SMACC Chicago. He is a highly decorated speaker with qualifications in astrophysics, medicine, anaesthetics, engineering and ICU, as well as a regular TV guest star on BBC2 show Horizon, NASA advisor and co-founder, co-director of CASE medicine. He spoke to us about how we can protect ourselves and our patients from risk and how we can better our skills in medicine. We will be sure to catch him at SMACC Dub next year!
Tor Ercleve talks about Resuscitating Art...diving into the world of infographics, symphonies and battle planning. You'll leave this talk refreshed and inspired to reinvent the way you communicate information. This talk was recorded at the smaccGOLD Get Creative Workshop. To see the talk with slides check out www.intensivecarenetwork.com/tor-ercleve-resuscitating-art
SMACC BACK!
In the third interview of the series, Sophie and myself get the opportunity to discuss all things ECMO with leading experts of ED ECMO, Joe Bellezzo and Chris Ho.
Following their highly entertaining cage match at SMACC Chicago in which Joe and Chris are forced to take opposing sides on ED ECMO, we get to hear their real opinions on how this equipment is becoming more and more accessible and valuable in the resus scenario. Between the friendly banter, Joe and Chris have some incredible insights into the future of ECPR.
We hope to see a lot more of these guys at SMACC next year!
SMACC BACK!
After an excellent talk at SMACC US which introduced us to #resus wankers , Dr John Hinds took time to chat with Sophie Connolly and Alice Young (ICU Residents from RNSH) about why SMACC is THE BEST conference, challenges for junior doctors and more!
We thank Dr John Hinds for his positive influence on critical care in Northern Ireland and throughout the extended CC community. He will be missed and our thoughts go out to his family.
SMACC BACK!
Scott Weingart takes time out between his entertaining and enlightening talks given at SMACC Chicago to chat with Sophie Connolly and Alice Young (ICU Residents from RNSH) about all things SMACC, the differences between training in the USA and Australia, advice for junior doctors and the origins of EMCRIT.
Check out this interview as a prelude to the release of the talks given at SMACC Chicago.
Charles Feldman is Professor of Pulmonology and Chief Physician at Charlotte Maxeke Johannesburg Academic Hospital. In this talk given at an ICN Victoria meeting last year, he discusses the alphabet soup that represent pneumonia phenotypes and clarifies what it's all about. His unique perspective on the history behind this incredible relevant topic is well worth hearing and hopefully clarifies some misconceptions.
HIV and ICU: the second ICN NZ talk from New Zealand's premier infectious diseases and HIV guru. He is consistently voted by the Auckland Uni Med students as their favourite teacher. Recorded live in Auckland, NZ.
Anthony Brown shares as an editor, the basics and tools of writing you need to use to maximise the c hances of your paper being published. This is a fantastic learning resource and comes neatly packaged within 15 minutes! The talk compliments Michelle Johnston's previous talk on The Artful Arrangment of Words. It was recorded at smaccGOLD's Creative Workshop.
Michelle Johnston, ED physician and author talks about the majesty in writing and how we can improve our skills. She brings us back to the often overlooked basics on the english language and how we can harness them to create a call to action, assert our research more clearly or simply improve everyday writing. This talk was recorded at the smaccGOLD Get Creative/Express Yourself workshop.
This Get Creative: The Art of Communication workshop will be held again with new and exciting material at smaccUS this June. Don't forget to register/add on to your registration. http://www.smacc.net.au/program/workshops/
John Myburgh takes us through 200 years of fluids therapy in critical care in one powerful presentation. He discusses the essential moments from history that changed the way we practice today and puts this long an bizarre story into context.
He covers the key aspects of relevant physiology and, inspired by Kipling, the what, where, when, how, why and whom of this intervention that has become synonymous with critical care. He tackles starch controversies with his unique perspective on the subject, as well as the very topical chloride debate and the upcoming SPLIT trial.
Best watched with John's superb slide deck.
WARNING: this may leave you questioning something you prescribe every day and feeling disturbed that something you assumed to be simple and sorted is far from it.
Other talks from John Myburgh include:
Beta Blocker and Sepsis
Fluid Resuscitation 2013
Decompressive Craniectomy
Catecholamines, resuscitation & resurrection
Day and Olusanya discuss key articles from the July 2014 edition of JICS (Journal of the Intensive Care Society). These include: management of diabetic ketoacidosis, a review on oxygen therapy and a look into ECHO in diagnosis of pulmonary embolism.
This journal is open access and can be found here: http://inc.sagepub.com/content/15/3.toc
Prof. Darren Heyland speaks to Dr David Gary and Dr James Day about Critical Care Nutrition. He discusses the PEP UP protocol for enteral feeding and the NUTRIC Score for identifying patients that may benefit from agressive nutrition therapy. This talk was first posted on www.intensivecarenetwork.com
Olusanya and Day are back with an interesting interview with Ron Daniels, the head of the UK Sepsis Trust. Daniels discusses the worldwide effort towards working for greater recognition and earlier treatment of sepsis. World Sepsis Day 2015 is on September 13th. For references of this talk and more information check out our post on www.intensivecarenetwork.com
David (@expensivecare) breaks some bad news: you are going to die. And so are many of your patients. Whilst many of us are pretty competent at bring people back to life, managing death well is a completely different skill set. David offers some very practical tips in this witty and incredibly relevant talk.
This is in the Pecha Kucha format so if your life only has a 6.40 hole, plug it!
This was also recorded live in David's local sushi bar in Erskineville for an ICN NSW night powered by Pecha Kucha in the PK format of 20 slides, 20 s per slide.
Shay McGuinness talks about what ECMO is, the history of its use in New Zealand and how their ECMO retrieval system works there. This was recorded live at the inaugural ICN NZ meeting, with support from ANZICS NZ.
Hussain (@HussainKadim ) takes us through what trauma is and means today, and how the network of trauma services becomes more than a sum of its parts. An interesting perspective on the big picture which is so easy to loose sight of.
This is in the Pecha Kucha format so if your life only has a 6.40 hole, plug it!
This was also recorded live in a sushi bar in Erskineville for an ICN NSW night powered by Pecha Kucha in the PK format of 20 slides, 20 s per slide.
Whilst faeces may not be the most glamorous of topics, the bowel habits of the critically ill matter. In Code Brown: Poo in the ICU, Claire takes us through the nuts and bolts of what faeces are, what to do if the consistency is wrong, the pitfalls of faecal management systems and why Bowels deserve their place in the ABC of resuscitation.
Sumesh Arora goes through the key intensive care aspects of managing the patient who's just had an oesophagectomy.
These patients can test the best of us and when it all goes wrong it's not pretty. This is in the Pecha Kucha format so if your life only has a 6.40 hole, plug it!
This was recorded at the ICN night powered by PK last December.
Go to www.intensivecarenetwork.com for more.
This podcast was recorded backstage at the Critical Care Reviews Meeting in January 2015 at the Galgorm Resort in Northern Ireland.
The meeting is hosted annually by Rob Mac Sweeney, the creator and curator of the awesome Critical Care Reviews website.
The intro and outro track is from Spiedkiks "Take off your make up", a creative commons free music download.
Danielle discusses the intensive care management of acute liver failure, including future directions for treating this devastating condition.
This was also recorded at the ICN NSW meeting in the Pecha Kucha format of 20 slides, 20 s per slide, so it's waffle-free and well rehearsed!
Go to www.intensivecarenetwork.com for more!
Recorded live in a Sushi Bar in Erskineville for an ICN NSW night powered by Pecha Kucha, this is a succinct presentation on Ventilation in acute severe asthma.
With 20 slides and exactly 20 seconds per slide, Jude summarises the priciples behind ventilating one of the most terrifying types of patient we encouter: the acute severe asthmatic.
Recorded live in a Sushi Bar in Erskineville for an ICN NSW night powered by Pecha Kucha, this is a succinct presentation on Ebola.
20 slides, exactly 20 seconds per slides and in 6 min 40s, Sara has encapsulated where we're up to with Ebola.
Day and Olusanya present many interesting articles from the Journal of the Intensive Care Society. They discuss a case of coagulopathy on novel anticoagulants, riginal research on use of automatic acceptance criteria to improve patient transfers. and intensive care follow up of UK military casualties.
All the articles are #FOAMed and can be accessed from: http://inc.sagepub.com/content/15/2.toc
Want to know how you can be useful when the call goes out to join the "other" Mile-High Club?
Dr Ian Hosegood is the medical director for a major international airline, and has extensive experience with pre-hospital care.
In part two of this entertaining talk, he discusses the policies and training of airline staff, how medically qualified volunteers can be useful, and might even touch on how to get an upgrade...
Hergen Buscher gives you an update on what's new and happening in ECMO.
Hergen has been working with ECMO for over a decade gives a great talk on this ever evolving field. If you are working with or will work with ECMO, this talk is essential listening.
His superb slides are available on www.intensivecarenetwork.com.
David Gattas gives an update on today's go-to anti-coagulant for renal replacement therapy.
David is an ANZICS CTG power player, with a growing list of publications and was involved in the RENAL and POST-RENAL studies.
This was recorded live at an ICN NSW / ANZICS meeting in September 2014.
Associate Professor Dave Pilcher is an Intensive Care Specialist at the Alfred Hospital and chair of the ANZICS Centre for Outcomes and Resource Evaluation (CORE) and an Associate Professor with the Department of Epidemiology and Preventative Medicine at Monash University.
He talks at our August 2014 educational meeting on the improving mortality in Australasia from sepsis and discusses some of the reasons for it.
A google hangout discussing the latest study on Early Goal Directed Therapy - ARISE. Featuring Anthony Delaney, Simon Carley, Segun Olusanya, James Day, Minh Le Cong, Jonathan Downham and Oli Flower.
When does age transition from being an asset to a liability? Segun Olusanya and James Day interview Chris Thorpe on the intriguing question of whether increasing retirement age of ICU consultants affects personal health and patient safety.
Karin Amrein is the lead author of the VITdAL-ICU trial that was just published in JAMA. Hear her real take on the results, implications and how she did it with two young kids.
THE ARISE STUDY: ARISEN Anthony Delaney is a lead PI for the recently published ARISE study
Listen to his take on ARISE and:
- The clinical bottom line
- Why it was a feat in itself pulling off such a study
- What is true dogmalysis
- The future for sepsis studies
- His take on EMCrit's Scott Weingart's interpretation
- His responses to EMCrit listener's comments
Above all, the take home points are in line with Scott's:
- Give the right antibiotics early
- Get source control ASAP
- Be careful at intubation
- Give the right amount of fluid for your patient (I know...)
- Early judicious use of vasopressors
- Admit the patient to an appropriately monitored area
Sepsis kills thousands every year. Finfer discusses what sepsis is and we can improve the morbidity and mortality from this familiar but enigmatic foe. See www.intensivecarenetwork.com for more...
Simon Finfer is a leading critical care clinical researcher. Hear his candid talk on the reality of research and publication and why it's relevant to you! Go to Intensive Care Network for the slides, videos and more.
Stan Yastrebov is an echo guru and an ICU professor of echo at St George hospital in Sydney.
In this talk that he gave at an ICN NSW meeting last month he goes through the nuts and bolts of haemodynamic assessment with echo.
Whether you're a novice or a regular echo user in crit care, this talk has something for you.
Echo talks can be a bit boring but Stan's energy and enthusiasm really come across and his accent was one reason trainees came from all over Sydney to hear this talk.
Nicola Stanley describes how ultrasound has changed the way we do critical care procedures and in the video, shows you a few new tricks.
It's only two months until the Bedside Critical Care Conference, and this year is looking like a cracker!
We're going back to tropical Cairns for the crit care conference with a difference – small, friendly and packed with superb practical crit care education.
After popular demand we’re going back to beautiful Queensland in the September/October school holidays. Come to the gateway of the Great Barrier Reef at the perfect time of year, where you’re guaranteed to have a great time, whether you’re there with your family or you’re there for an adventure and a party. Or both.
The program this year is all new but follows the popular format of short, practical lectures on clinically relevant crit care topics, and small group workshops with experts teaching you what's not in the books.
The Intensive Care Network registrar's day is on the Monday, at a massively discounted rate and has some great bread and butter talks. These include talks on fluids, sedation, nutrition, airways, ECMO and advanced ventilation.
On the main program there will be sessions on trauma, microbiology, palliative care and end-of-life situations, paediatrics, coagulation and some panel discussions that mustn't be missed.
The workshops will tackle airways once again, end-of-life discussions, some great kit including the ROTEM and Metabolic Carts, as well as some advanced haemodynamic stations, dialysis and crit care radiology.
Of course the social program will be special, with a Welcome Reception that is for everyone, including kids and partners and the Gala Dinner promises to be infamous once again.
Cairns is a special destination for so many reasons and there are plenty of activities to cater to everyone’s tastes. Whether you want to take the kids to the Wildlife Dome, cruise by catamaran to the paradise that is Green Island or take the cable way up to Kuranda Village over the world heritage rainforest, it’s all doable. We’ve arranged discounted prices for these excursions that you can book on the website.
There are still a few spots left so don’t have any regrets – book today!
Listen to the 6 minute podcast for more info…
Sam Radford and Julian Van Dyke will help keep you ever-ready in and out of ICU with their talk on simulations and debriefing. This podcast was recorded at the July Victorian Intensive Care Network meeting.
Li Tan is an Intensivist and Echo Fellow at St George hospital in Sydney. She has a particular interest in critical care echocardiography and in this talk describes how useful it can be when investigating obstructive shock.
Out of hours (OOH) care remains a challenge in all medical specialties round the world. Day and Olusanya interview Owen Roodenburg from the Royal Alfred, Melbourne, about an innovative approach to managing OOH care in hospitals. This new programme directly addresses many of the issues with night time staff cover and allows selected trainees to obtain a Certificate of Clinical Leadership centred around experience, exposure, and education.
ICU as the centre of the hospital of the future? Listen to hear more!
You can read the article published in JICS here: O’Leary R, Strange J, McKimm A, Gantner D, McClure J, Roodenburg O. ICU should improve the night-time hospital. JICS October 2013; 14, 4: 284-287 (free full text at http://journal.ics.ac.uk/pdf/1404284.pdf )
Cartan Costello is an Intensivist from St George hospital in Sydney. He has a particular interest in critical care echocardiography and in this talk describes how useful it can be for trauma patients. Go to www.intensivecarenetwork.com for the slides and video.
1.6 million people are on the Australian Organ Donation Registry. How do you approach organ donation with your patients? Steve Philpot speaks at the May VIN meeting about how we can better facilitate organ donation and about the usefulness of the donation registry.
Rupert Pearse discusses the importance of results from the OPTIMISE trial to improve perioperative patient management.
Gerard Fennessy interviews Associate Professor Daryl Jones (Austin Hospital, Melbourne) on Medical Emergency Teams. They discuss how such Rapid Response Teams have developed across the globe and how they have improved critical care delivery.
Gordon Flynn is an Intensivist and an Anaesthetist from Prince of Wales hospital in Sydney.
Here he gives an entertaining and thought provoking talk on the big topic of obesity in ICU.
Leave comments below on ICN!
David Bihari is an Intensivist from Prince of Wales Hospital in Sydney. He is particularly interested and passionate about nutrition in the critically ill, and has been involved in research in this area for many years.
Check out what's new in the Journal of the Intensive Care Society with James Day and Segun Olusanya. They discuss new research on futility of care, nurse led tracheostomy weaning and concerns with work-related health problems for ICU staff.
Ravi Tiruvopati discusses hypercapnia in ICU patients, particularly for those with severe respiratory failure. This podcast was recorded during a VIN meeting in January.
Stephen Warrillow speaks about liver failure at a VIN (Victorian Intensive Care Network) meeting.
Segun Olusanya and James Day interview Karim Brohi on his talk about coagulation in trauma. This interview was recorded during the State of the Art Conference in London earlier this year. Brohi is the author of Trauma.org
Stephen Warrillow is an Intensivist from the Austin Hospital in Victoria. Here he discusses the care of a liver transplant recipient in intensive care.
Tim Crozier is an Intensivist from Monash in Melbourne.
Here he talks about Obstetric morbidity for the Intensivist.
This was recorded live at a ICN Victoria meeting.
Delaney shares insights into the mysterious world of statistics and trials. This 12 minute podcast is particularly useful for Registrars preparing for their exams and was recorded at BCC4.
Anthony Tzannes talks on how mushroom poisoning happens and gives an array of practical and creative ways to treat it. This talk was recorded at BCC4. Check out www.intensivecarenetwork.com for more talks or hit up www.bedsidecriticalcare.com to rego for this year's conference.
Fran Lockie, provides a useful update on the outcomes and issues with paediatric drowning. This talk was recorded at Bedside Critical Care Conference. The next BCC will be held in Cairns, 29th September - 3rd of October: http://bedsidecriticalcare.com/
Toxicologist, Mark Little dives into marine envenomation, with particular attention to the dangers of jellyfish. This talk was recorded at BCC4. Don't miss out on the fantastic upcoming BCC5 this September 29th- October 3rd in gloriously sunny Cairns. http://bedsidecriticalcare.com/
Present and future cardiothoracic intensivists will enjoy this talk by Brian Plunkett on thoracic aortic dissection given at BCC4.
Enrich your knowledge of cardiac ultrasound with the help from experienced sonographer, Sharon Kay. Sharon covers a focused cardiac ultrasound of the heart, and gives examples of emergency cardiac conditions that can be detected with this versatile modality. This talk was recorded at Bedside Critical Care Conference 4. For the full post and other BCC4 posts, head over to www.intensivecarenetwork.com
Marek Nalos takes us on a mission to explore the myth of lactic acidosis. Marek is an intensivist and the Director of Trauma for Nepean Hospital. This talk was recorded at BCC4.
To thin or not to thin? That is a puzzle that Sarah Wesley helps answer with her interactive talk on anticoagulation and the heart. This podcast was recorded at BCC4.
Pierre Janin speaks on the dawn of a revolution for treating Hepatitis C. This was recorded at BCC4.
Intensivist Jon Gatward speaks at BCC4 about Liver Transplantation. His informative talk covers complications including post-reperfusion syndrome, biliary complications, hepatic artery thrombosis and 'other badness'. It also explores DCD livers and issues for retransplantation. Keep up to date with slides and posts on the intensivecarenetwork.com
Clive Woolfe, Irishman and RPA Intensivist, speaks at Bedside Critical Care Conference. In this podcast, he gives an overview of the prognostication and management of chronic liver disease. See www.intensivecarenetwork.com for the slides and post.
Anthony Delaney, on of the key Investigators in the ARISE trial discusses the recent results from the ProCESS trial and what this means for sepsis management at the right now. The Surviving Sepsis Campaign statement is here and paper Anthony mentions describing the differences between the three sepsis trials is here.
David Anderson gives an entertaining and informative talk about Acute Liver Failure at BCC4. He covers a good approach to thinking about diagnosis, management and prognosis of acute liver failure.
Segun Olusanya and James Day are back, interviewing Professor Art Slutsky, an expert in respiratory failure and adult respiratory distress syndrome. Art shares how his engineering experience has helped shaped his career and about his research and involvement in redefining ARDS. Check out the great references for this talk at the Intensive Care Network website: www.intensivecarenetwork.com
Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.
Minh Le Cong (@rfdsdoc), speaks on agitation in the ICU. His punchy talk covers why agitation happens (on both sides) as well as strategies for managing the agitated patient. The potential of ketamine use for agitation and refractory depression is also discussed. This great podcast was recorded from the Bedside Critical Care Conference 2013.
Craig Hore gives a great case based discussion of on trauma and CTA of the neck and thorax, all in under 15 minutes. This talk was recorded at BCC4.
Cohen talk at a Brisbane Intensive Care Network meeting on 'The Problem with Sepsis Trials'. Get excited to hear him speak at smaccGOLD next week! For more information about state based ICN events, check out www.intensivecarenetwork.com and head to 'Regional Networks'.
Pierre Janin talks targets in neuro-icu, zoning in on blood pressure management in patients with ICH. This resource was recorded at Bedside Critical Care Conference 4.
James Day and Segun Olusanya have some interesting thoughts to share about the latest edition of the Journal of the Intensive Care Society's latest issue from October 2013. There are reviews on pain in intensive care, original research on ECHO services and effect of admission timing on mortality and more. To see references and past posts, head over to intensivecarenetwork.com
Steve Bernard speaks at a meeting on 4/2/14 in Sydney on the reality of ECMO CPR at The Alfred in Melbourne, Victoria, and the upcoming CHEER study.
Exciting times!
Celia Bradford talks about prevention and management of vasospasm after subarachnoid haemorrhage. This talk was recorded at Bedside Critical Care Conference 4.
[Full Audio] Oli Flower discusses the tricky issue of prognostication in neuro disasters. This includes intracerrebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage and ischaemic stroke. From Bedside Critical Care 2013 in Cairns. Go to Intensive Care Network for the audio and much more.
Anders Aneman was an investigator and author of the TTM trial.
Hear this podcast on where we go from hear in cooling post out-of-hospital cardiac arrests.
See Intensive Care Network for more details.
Delaney helps highlight recent research into pre-hospital intubation and intracranial pressure monitoring for patients with TBI. This talk was recorded at Bedside Critical Care Conference 4.
Jon Gatward discusses how we can fight risk and by making plans to help us prevent airway complications in the ICU. This fantastic talk was recorded from BCC4, Cairns.
John speaks on how we should intubate and who should intubate within the ICU. This podcast recorded at BCC4.
This great talk from BCC4 features Clare Farell, an anaesthetist from Westmead Hospital, speaking on modified rapid sequence induction.
"If you don't take a temperature, you can't find a fever...(The House of God)" James Sartain cleverly uses case studies to highlight attitudes, issues and management of acute pain in ICUs. He'll make you think as he uncovers the discrepancies between guidelines and clinical practice. This podcast was recorded at BCC4.
Sean McManus distills valuable knowledge about airway management in his talk on "The Ultimate Induction". This podcast was recorded at Bedside Critical Care Conference 4.
Sarah Wesley, training supervisor at Royal North Shoe Hospital discusses new changes to the training pathways for ICU and critical care registrars in 2014. This podcast was recorded at BCC4, Cairns.
In this podcast from BCC4, Roger Harris gives an interesting talk on donation after cardiac death. He covers the history and practical philosophy behind DCD as well as talking through his own experiences with patients.
Gordon Flynn works as an intensivist, organ transplant advisor and anaesthetist. In this podcast from BCC4, he speaks on surgical considerations and intensive care of the deceased.
Oliver Flower speaks about Brain Death and organ transplantation at 2013's Bedside Critical Care Conference.
Viewing the slides along with the talk is recommended.
Craig Hore gives sound advice and encouragement for when and how to refuse admission of inappropriate patients to our intensive care units. This podcast was recorded at BCC4 in Cairns.
In this podcast from BCC4, Anthony Tzannes discusses his methods for alveolar recruitment.
Michael Parr, director of Liverpool ICU, speaks at BCC4 on ICU care for patients post cardiac arrest.
Georgie Harris gives an ENT perspective at Bedside Critical Care Conference 4 on how to approach and manage patients with massive epistaxis.
Fran Lockie is a Paediatric Emergency and Retrieval physician currently based in Adelaide. In this podcast, he speaks at Bedside Critical Care Conference 4 about how Kids are Little Adults.
Bedside Critical Care Conference 4 in Cairns, Australia in 2013 was a great hit. This short podcast from Oli Flower and Roger Harris discusses the highlights of BCC4 and how these will be shared in the spirit of FOAM on the Intensive Care Network. So look forward to the upcoming videos, podcasts and slides from the workshops and talks given at this conference!
Daydd Thomas speaks at a recent SIN meeting about effective patient blood management.
This is the second of two talks, with the first by Bruce Cartwright found here.
James Day and Segun Olusanya interview Dr Nicholas Barrett, a consultant in ICM at St Thomas' Hospital involved in the severe hypoxia service.
Oli Flower discusses the changing landscape of critical care education and what new media means in this context. Best listened to with slides. See Intensive Care Network for more.
Matt MacPartlin talks to Niklas Nielsen, the author of the recently published TTM trial, and Anders Aneman, one of the local site investigators about this game-changing study.
Dr Priya Nair is a senior intensive care specialist at Sydney's St Vincent's Hospital and an expert in managing patients with cardiac assist devices. In this talk she takes us through the key issues encountered when on managing patients with left ventricular assist devices. As LVADs are becoming more widespread, this inside know-how is invaluable to all of us. They physiology and technology involved with these devices is pretty amazing.
Cardiologist and Associate Professor Chris Hayward talks at SIN. He broadens our understanding of mechanical cardiac assist devices and their use in clinical practice.
The UK intensivists Olusegun Olusanya and James Day are back to keep you up to date with recent literature including blood transfusions in intensive care, B2 agonists in ARDS and ICP monitoring for TBI. Their discussion is based around the July 2013 edition of the Journal of the Intensive Care Society (JICS).
The articles mentioned are found at the following link: http://journal.ics.ac.uk/journal_article_detail.html
Matthew Mac Partlin talks about emergency airways access. Make sure you listen or watch this on www.intensivecarenetwork.com before Matthew's workshop on cricothyroidotomy at BCC Cairns!
This podcast is Michael Rose talking on anaphylaxis. Michael is an anaesthetist in Sydney and a leading expert in the world of anaphylaxis. He talks about the basics and recent developments in this field - an area of critical care relevant to us all. His website http://www.anzaag.com has many useful resources, including validated management algorithms that you can use use in your department.
His Holiness the Dalai Lama spoke at Westmead hospital recently on "Navigating the Ethics of Modern Medicine". Fitting for our 100th podcast, thei Great man talks about organ donation, his own experiences with healthcare in recent years, the history of medicine in Tibet and has advice for us all about how to treat our patients. A transcript is available here too. A classic!
Richard Levitan is widely regarded as the global master of the emergency airway.
And he's keynoting at SMACC GOLD.
He was recently in Sydney, teaching on a cadaveric airways course with John Vassiliadis (of Simwars fame and mastermind behind EDWISE).
Rich talks about his global travels, his airways courses and his exciting new emergency surgical airway kit. John tells us about EDWISE, simulation and why he's pumped for SMACC GOLD. Harris provides entertainment whilst the hype for SMACC GOLD starts to swell.
Pierre Janin has spent a long time distilling down the essence of ultrasound physics into two short talks.
This second presentation really focuses on Doppler and has made some great animations to make this potentially confusing topic easy to understand.
Again, this is essential knowledge for anyone who is involved with ultrasound...so watch this, REPETITIVELY!
The first video is here
Pierre Janin has spent a long time distilling down the essence of ultrasound physics into two 10 minute talks.
This first one covers some history and basic theory and is essential knowledge for anyone who is involved with ultrasound... so that's all of us then?
Christine Bowles, an ED and trauma consultant, hosts a discussion on the controversial topic of clearing the C-Spine.
The discussion involves Donovan Dwyer, (Emergency Physician), Andrew Cheng (Intensivist) and Anthony Morgan (Trauma Surgeon) and takes us from the front door of the emergency department to several days down the track in the ICU.
James Day and Olusegun Olusanya interview Duncan Young, Director of Research for the UK Intensive Care Society about his work in the TracMan Trial. Young discusses the results of the trial as well as challenges with clinical trials and directions for future research. He also gives a few tips for young doctors looking to get involved with research.
The recently published paper in JAMA on the TracMan trial is found here.
JICS is the Journal of the Intensive Care Society and is in the process of becoming indexed on Medline.
James Day and Olusegun Olusanya interview Duncan Young from Oxford about his work and the High Frequency OSCillation in ARDS (OSCAR) Trial.
Alex Rosenberg is an intensivist with more of an obsession with all things cardiac, but his experience in a large neuro ICU made him well placed to discuss the interaction between cerebral perfusion pressure, vasopressors and cardiac output. This is an important neuro topic that is relevant to anyone who looks after patients with injured brains.
This is sadly the last talk from BCC3, but don't get too depressed - you can always join us this year in Cairns, or wait for those talks to come out on ICN, and there's always the torrent of superb free media that is flowing out from the smacc conference.
Matthew MacParlin wraps up his TBI series by talking about prognostication as well as ICU management of neuroprophylaxis and seizure prophylaxis.
Always controversial, always entertaining, the fearsome but loveable Geordie Stuart Lane gives an excellent summary of a core ICU topic: managing out of hospital cardiac arrests.
We're nearly at the end of the BCC3 series - and in only a month we're doing it all again, this time in tropical Cairns - come and join us.
Matthew MacPartlin continues his four part series on traumatic brain injury with a focus on how to manage these patients in ICU.
See the intensivecarenetwork.com website for references and slides.
Matthew MacPartlin continues his four part series on traumatic brain injury with a focus on how to manage these patients in ICU.
See the intensivecarenetwork.com website for references and slides.
Oli Flower presents a case of headache with an unusual diagnosis. Hopefully thought provoking. The slides can be seen separately on www.intensivecarenetwork.com and the links to relevant resources can be found there too. This was presented at last years BCC in Daydream island
Matthew MacPartlin continues his series by discussing how to approach an ED admission of TBI.
Useful references for this talk are found on the ICN website: www.intensivecarenetwork.com
Matthew MacPartlin begins his four part series on traumatic brain injury with a brief overview of epidemiology, aetiology and features.
The UK intensivists Olusegun Olusanya and James Day are back to keep you up to date with recent literature. Their discussion is based around the April 2013 edition of the Journal of the Intensive Care Society (JICS).
The articles mentioned are found at the following link: JICS April 2013
Many thanks to Segun (@iceman_ex) and James for involving ICN with sharing this JICS Cast.
Research guru and PI for the ARISE study, college examiner and semi-professional forrest-based carpenter, Anthony always gives a fascinating talk. This time he gives an intelligent and considered breakdown on the nebulous topic of cerebral protection.
Fran Lockie is a Paediatric Emergency and Retrieval physician currently based in Adelaide. He is quickly becoming a leading expert in paediatric TBI and so was the perfect person to give this talk. The slides that go with it are on Intensive Care Network. If you like these sorts of presentations, come along to Cairns Bedside Critical care this September where we've got a great line up of speakers and we're doing it all again.
The second serving from the UK intensivists Olusegun Olusanya and James Day.
They discuss recent literature based around the January 2013 edition of the Journal of the Intensive Care Society (JICS).
The articles mentioned are found at the following link: JICS January 2013
Many thanks to Segun (@iceman_ex) and James for involving ICN with sharing this JICS Cast.
A podcast discussing the forth coming Developing EM conference, discussing how and why it came about and why Havana is the place to be this September. With Mark Newcomb, Lee Fineberg, Roger Harris and Oli Flower. See www.intensivecarenetwork.com for more details.
A brief promo for BCC4 with a discussion about what's in store and what the highlights may be. With Roger Harris & Oli Flower. To book for BCC4, click here.
From the UK, Dr Olusegun Olusanya and Dr James Day discuss recent intensive care literature based on the October 2012 edition of the Journal of the Intensive Care Society (JICS).
The articles mentioned can be found here: http://journal.ics.ac.uk/journal_article_detail.html?edition=19
Many thanks to Segun (@iceman_ex) and James for involving ICN with sharing this JICS Cast.
This talk was given at the last Victorian Intensive Care Network meeting. Dash Gantner is an ICU Fellow from Melbourne who has been at the cutting edge of research in the past couple of years, working closely with ANZICS CTG research guru, Jamie Cooper. Dash is not new to research and previously worked in China for The George Institute and mastered Mandarin whilst he was over there. Watch out for big things in the future with this one.
Professor Jamie Cooper is the Director of the Australian and New Zealand Intensive Care Research Centre, Monash University. He is well known for his contribution to ICU research, having published over 160 journal papers and being the Principal or Co-Investigator on numerous peer reviewed research grants, including 16 from the NHMRC.
This talk was given at the last Victorian Intensive Care Network meeting and is the first of two talks.
An interview with David Riggs, an intensivist from Hobart and the medical convenor of this year's ANZICS ASM. David explains more about what ANZICS is and does, and reveals what's coming up at this year's ASM.
Oli Flower gives an iconoclastic view of neurocritical care. This is a talk that was given at the College of Intensive Care Medicine's ASM in Wellington in June 2013. It focuses on three aspects of traumatic brain injury management: prognostication, transfusion thresholds and the role of ICP monitoring. For the references and more click here.
Michaela Cartner, an Intensivist and ED physician from Queensland's Gold Coast, gives a fascinating talk on environmental heat stress. The Marathon des Sables provided a perfect backdrop to discuss this important topic.
Go to www.intensivecarenetwork.com for the slides and more.
David Gattas is an Intensivist and clinical researcher from Royal Prince Alfred Hospital in Sydney.
Known for his dry wit and calm composure under fire, David is a rising power player for the ANZICS CTG and was heavily involved with the recent CHEST study.
This talk was given at a Sydney Intensive Care Network meeting.
Go to www.intensivecarenetwork.com for the podcast and more.
Roger Harris, the Bedside Critical Care big dog gives his last talk of the 2012 conference.
From the maker of Sex and Nutrition comes Oxidative Stress.
Roger specifically discusses:
- What is Oxidative stress
- Why is Oxidative Stress important
- How does Selenium fit into Oxidative stress
- Selenium (Se) in critical illness
- What’s the current evidence for Se in ICU
How safe is your hospital for a patient with a tracheostomy? Sean Kelly from the Intensive Care Coordination Monitoring Unit (ICCMU) talks with Tony Burrell from the Clinical Excellence Commission and Ian Seppelt about improving the safety of patients with tracheostomies in and out of the ICU…….managing tracheostomy airway emergencies, before and when the cavalry arrives……and the recently released ICCMU guideline, "Adult Patients in Acute Care Facilities with a Tracheostomy" . The guideline and other resources to help implement the guideline in your hospital can be accessed at ICCMU here
Alex Rosenberg is an Intensivist who was working in a transplant centre last year. He gave this talk on immunosupression at last year's Bedside Critical Care Conference and managed to make a fairly dry subject seem understandable and relevant. Go to www.intensivecarenetwork.com for the slides and more...
Pierre Janin is an intensivist with many interests. For example you may have seen his fantastic echo guide or his talk on transcranial doppler. One of his other passions is microbiology, and at BCC last year he gave this talk on Fungal infections. He often proudly shows pictures of his fungal balls on ward rounds.
Anthony Holley, a world famous transfusion and coagulation guru, draws on his military, ED and ICU experience and talks about the most recent blood transfusion guidelines. They are a great resource and can be downloaded here. This talk is different to the last one he gave at Bedside Critical Care 2012!
Niklas Nielsen is an academic intensivist from Helsingborg, Sweden. He is the mastermind behind the Targeted Temperature Management Trial, a landmark international multicentre clinical that has sought to answer a question that many believed has already been answered: What is the optimal target temperature following out of hospital cardiac arrest?
The TTM trail has finished recruiting and the protocol can be seen here. The results will be out later this year.
So...
READ Niklas' FASCINATING paper which really lays down the rationale for the study
LISTEN to this podcast interview with Niklas
LEAVE some feedback if you have any comments on this controversial and emotive topic
KEEP an open mind about this topic!
A Pecha Kucha discussing prognostication following aneurysmal subarachnoid haemorrhage. This includes discussion of the various grading scales used and other factors that impact upon prognosis. This is the 5th of 5 Pecha Kuchas on this topic.
A Pecha Kucha discussing the complications that may follow aneurysmal subarachnoid haemorrhage. This includes causes of a neurological deterioration, seizures, hyponatraemia, cardiac complications, re-bleeding and hydrocephalus. This is the 4th of 5 Pecha Kuchas on this topic.
A Pecha Kucha discussing vasospasm following aneurysmal subarachnoid haemorrhage. The terminology, pathology, risk factors, diagnosis and management are discussed within the limitations of a PK. This is the 3rd of 5 PK's.
A Pecha Kucha discussing the intensive care management of aneurysmal subarachnoid haemorrhage. This includes glycaemic control, haemoglobin targets, venous thromboembolism, fever, volume monitoring and fluid therapy. This is the 2nd of 5 PK's.
A Pecha Kucha introducing the topic of aneurysmal subarachnoid haemorrhage. This includes some epidemiology, the initial management and some treatment options. This is the first of five Pecha Kuchas on this topic.
Paul Lane is an intensivist from Townsville, in the tropical north of Queensland, Australia. He gave this talk at last year's bedside critical care conference straight after Ed Morris' talk on the same subject. In this talk, Paul brings the intensivist's perspective. Not too late to join the 550 others coming to SMACC - see the website for details and see ICN for Paul's slides that go with this talk.
Ed Morris is an Englshman currently hailing from Townsville, Australia who is a superb haematologist. He gave this talk on haem malignancies with specific regards to the critical care aspects at last years bedside critical care conference. The slides are available for free on Intensive Care Network.
Sumesh Arora, an intensivist from Prince of Wales Hospital in Sydney talks about what dysbarism is, and the role of hyperbaric oxygen therapy. See the slides on Intensive Care Network.
The next BCC talk is by Cath Tacon, an Intensivist who is currently working in Alice Springs. In this talk, Cath tells you everything you need to know about Lipid Rescue Therapy. Incidentally Cath has just written an excellent review paper on bacterial meningitis in kids, which is free access and the link is on Intensive Care Network.
Listen to LITFL's Chris Nickson give 5 pearls on managing cardiotoxic drug overdoses. Punchy and memorable. Never surrender! The excelllent slides are available for free on Intensive Care Network.
Sean Kelly is an Emergency Physician and Intensivist who's the director at Gosford ICU in New South Wales. He's also the medical director at ICCMU. He gave this great talk at Bedside Critical Care 2012 on Daydream Island. He'll be at SMACC. Check out the ICCMU website. Register for SMACC now! See the slides for this podcast at Intensive Care Network.
To open 2013 we've got a podcast that will get your attention. It's on a topic that makes any sensible critical care practitioner sweat more than a little bit: obstetric emergencies.
Nhi Nguyen is an intensivist from Nepean Hospital that specialises in fetomaternal medicine and even she admits it's stressful. Here, Nhi goes through some cases that are easy to relate to and covers the most important topics. It's a bit longer and in more depth than her last taster.
Go to Intensive Care Network to see the slides and add comments.
Image credit
Anthony Holley's fantastic presentation on burns that he gave at the Bedside Critical Care Conference 2012. This one had the audinece in stitches with Anthony's tear-inducing anecdote and really showcases how well they manage burns in Brisbane. Go to www.intensivecarenetwork.com for the slides.
Roger Pye is a world-leading ECMO specialist. This talk on starting ECMO during CPR resuscitation is serious, and backed up by some extraordinary cases. Roger presents his experience and the literature on this topic.
The presentation can be heard on wwwintensivecarenetwork.com
Anthony Delaney, an Emergency Physician and Intensivist from Sydney gives an update on Sepsis Resuscitation in 2012, discussing the latest literature and evidence. And he doesn't even talk about ARISE (much)!
The slides and notes are available on Intensive Care Network.
Fran Lockie, a Paediatric Emergency and retrieval specialist, gives an update on Paediatric Resuscitation in 2012.
This talk was given at the Bedside Critical Care Conference 2012 on Daydream Island.
See Intensive Care Network for the slides and to leave feedback.
Andy Wilkinson and Eamonn Sheerin are registrars currently working in ICU in Sydney. They are relatively new to ICU and have been looking into why we do some of what we do on our daily ward rounds.
This podcasts focuses on ways of remembering the important things that can be forgotten and in particular stress ulcer prophylaxis and venous thromboembolism prophylaxis.
Eamonn is the Talking Heads fan and Andy has a soft spot for East 17.
Chris (@precordialthump)'s interest in tropical medicine and envenomtion has lead to him becoming a national expert on the matter. This talk on spider bites and marine envenomation covers the latest research on the subject. Best watched with the accompanying slides. This talk was given at the Bedside Critical Care conference 2012. The slides and credits are on Intensive Care Network here
Chris has been into envenomation ever since I've known him, when we met in Darwin. He has worked with some world experts in this area, been involved with important research and been exploring places such as Sri Lanka looking for some of the world’s most dangerous snakes, which worries me a bit as I’m going back there next month. This talk was given at the Bedside Critical Care conference 2012. See here for the ICN article with slides and credits.
This very brief podcast features Roger Harris explaining the biochemisrty of sodium in the context of hyperglycaemia. It follows a conversation that took place on Twitter between Roger (@rogerrdharris) and Seth Trueger (@mdaware) on this topic. The music snippet can be found here
Jon Gatward is an intensivist from Royal Prince Alfred Hospital, Sydney, with an interest in simulation and teaching.
He gave this lecture at Bedside Critical Care 2012 (#BCC3) following a simulated resuscitation scenario.
He describes the latest updates in Advanced Life Support and discusses some recent literature on the topic.
Jon Gatward, is an intensivist from Royal Prince Alfred Hospital, Sydney, with an interest in simulation and teaching. He gave this lecture at Bedside Critical Care 2012 following a simulated resuscitation scenario. He describes the latest updates in Advanced Life Support and discusses some recent literature on the topic.
Listen to this fantastic talk, watch the video and add comments your comments on www.intensivecarenetwork.com.
The music snippet can be bought here.
Stuart Lane, an Intensivist from Nepean hospital, takes saying sorry seriously. Seriously seriously. To the extent he's nearly finished his PhD on the subject. Listen to this fantastic talk, watch the slides and add comments your comments on www.intensivecarenetwork.com. The music snippet can be bought here.
Roger Harris gives a second presentation on further aspects of preparing for a critical care job interview. This was given at the Bedside Critical Care 2012 registrar's day. The slides are on Intensive Care Network. Sound credit here.
Neil Orford gives tips on how to optimise your CV when applying for a critical care medicine job. The slides are available on Intensive Care Network. Audio snippet credit here.
Stuart Lane, an intensivist from Nepean hospital, gives a 10 minute opinion on management of difficult airways in ICU, mainly focusing on videolayngoscopes. As always, Stuart gives us food for thought!
He gave this lecture on the Registrar day at the Bedside Critical Care conference 2012 (#BCC3).
The sound snippets are from "O Fortuna" which can be bought here
Michaela Cartner, an ED physician and intensivist, gives a down-to-earth fast paced low down on dialysis. She gave this lecture on the Registrar day at the Bedside Critical Care conference 2012 (#BCC3).
The sound snippets are from "O Fortuna" which can be bought here
Joe Ogg describes his approach to Acid Base intertretation. Recorded at BCC in Kingscliff 2012.
Paul Lane, an intensivist from Northern Queensland, gives a lecture about Melioidosis and Leptospirosis in the tropical north of Australia. This was presented at the registrars day at Bedside Critical Care 2012 and credits and slides can be found on Intensive Care Network.
Roger Harris, a senior ED physician and intensivist, gives tips on interview preparation. This was presented at the registrars day at the Bedside Critical Care 2012 conference. Go to Intensive Care Network for more details, slides and credits.
Nhi is an intenivist with a particular interest in Feto-maternal health. She gave this lecture at the Registrar's day at Bedside Critical Care conference 2012.
The slides are available at www.intensivecarenetwork.com
Chris Nickson of www.lifeinthefastlane.com fame gave this great, punchy 10 minute lecture on ABG's on the Registrar day at the Bedside Critical Care conference this year. The slides can be found at www.intensivecarenetwork.com.
Antony Tobin, a senior intensive care specialist from St Vincent's hospital in Melbourne, gives a talk on strategies for managing respiratory failure. This talk was given on the 17th of September 2012 at a Victorian Intensive Care Network meeting. This is the second part of the talk which focuses on HFOV. See www.intensivecarenetwork.com for more details. The music snippets can be bought here.
Antony Tobin, a senior intensive care specialist from St Vincent's hospital in Melbourne, gives a talk on strategies for managing respiratory failure. This talk was given on the 17th of September 2012 at a Victorian Intensive Care Network meeting. See www.intensivecarenetwork.com for more details. The music snippets can be bought here. Pic credit here.
Anthony Delaney (@thearisestudy) is a double medalled Emergency Physician and Intensivist who’s achievements include several high impact publications in major journals as well as keeping his chooks alive and away from his two little kids. He’s an intimidating college examiner that has confused many by looking like a bit like Robin Pecknold of Fleet foxes fame.
He is also THE Big Man (along with Sandy Peake and Rinaldo Bellomo and several other incredible reseachers) behind the ARISE trial, which is a multi-centre, randomised controlled trial of early goal-directed therapy in patients presenting to the Emergency Department with severe sepsis in Australasia. It involves 47 sites (including Australia, New Zealand, Hong Kong and Finland and possibly Ireland) and has enrolled 1095 pts. The trial commenced enrolment in October 2008. and is well on its way to completion.
The sound snippets are from Caspar Babypants which can be bought here.
See www.intensivecarenetwork.com for the article.
Anthony Holley gives a suberb and brief case-based talk on massive blood transfusion. This was recored at Bedside critical Care 2012. The sound snippets are from O Fortuna which can be bought here: http://itunes.apple.com/us/album/o-fortuna-from-carmina-burana/id333094640. The slides are available at www.intensivecarenetwork.com.
Roger and Oli debrief after BCC3, outline what went on and what the higlights were. This is a great prelude to the series of podcasts that are about to come out. Intro and exit snippets credit to M.I.A. and can be bought here: http://itunes.apple.com/us/album/kala-bonus-track-version/id262161787
Chris Nickson (AKA @precordialthump) gave the after dinner speech at Bedside Critical Care 2012 (#BCC3) and it was a cracker. See www.intensivecarenetwork.com for the hilarious slides. Powerful-talks-101 from the http://iteachem.net/ guru himself...
Intro and exit snippets credit to M.I.A., buy the track here.
An interview by Minh Le Cong AKA @rfdsdoc (of www.http://prehospitalmed.com/) with Scott Weingart (www.emcrit.org), Oli flower and Matt MacPartlin (www.intensivecarenetwork.com) all about the upcoming Social Media and Critical Care Conference which will be on 11th - 13th of March 2013. See www.smacc.net.au for more details...
Intro/exit snippets can be bought here: http://itunes.apple.com/us/album/o-fortuna-from-carmina-burana/id333094640
David Collins presents a fascinating tox conundrum at one of the Sydney Intensive Care Network meetings. Can you figure it out before he gives the answer? See the slides to go with this at www.intensivecarenetwork.com. Intro snippet by Nina Simone: http://itunes.apple.com/au/album/nina-simone-the-greatest-hits/id255987553.
At the inaugural Victorian Intensive Care Network (VIN) meeting, Vin Pellegrino gave and outstanding talk. Vin is a renounded and popular Senior Intensive Care Specialist at The Alfred Hospital and head of the ECMO Clinical Service. He has had a lead role in the development of the world leading ECMO service at The Alfred since 2003. His other interests are in circulatory physiology and control of the circulation. Vin gives a fascinating and original insight into haemodynamic physiology relevant to critical care. Listen to it here and go to www.intensivecarenetwork.com to get the slides.
Paul Young discusses the history of our interpretation of fever in sepsis and why it may not be a bad thing. We talk about the upcoming HEAT trial which hopes to take us one step closer to seeing whether paracetamol is a beneficial treatment in sepsis. More information is here (http://www.anzics.com.au/ctg/current-research/255-heat) and on www.intensivecarenetwork.com.
An exellent talk by a radiologist, Nivene Saad, on how to interpret MRI in the critical care setting. Also from last year's Bedside Critical Care conference (http://www.criticalcareevents.com.au/). Go to www.intensivecarenetwork.com to get the slides.
Listen to Professor John Myburgh's fantastic lecture on one of the hottist topics in critical care right now: Fluid Therapy.
Pierre Janin is a French Intensivist with an interest in all things ultra sound. Listen to his marvellous talk on the use of transcranial doppler in critical care. Please excuse the fantastic, but racially stereotyping Serge Gainsbourg backing track...
Paul Goldrick, the famous and much loved intensivist from Darwin, gives an excellent summary of prone ventilation and pulmonary vasodilators. This was recorded at the 2011 Bedside Criticsal Care conference. The slides to go with this presentation are available here: https://docs.google.com/open?id=0B9vT1_AbNNQSVGRneWZFRDZ4Z3c
Dr Priya Nair is a leading expert on the intensive care of transplant recipients. This excellent talk was recorded at the Sydney Intensive Care Network meeting at St Vincent's Hospital in Sydney on 03 05 12. The slides are available to download here: https://docs.google.com/open?id=0B9vT1_AbNNQSNEtuMFNZN1dzT2c and at www.intensivecarenetwork.com. Information about the bedside critical care conference can be found here: http://intensivecarenetwork.com/index.php/icn-activities/other-critical-care-events/282-the-ultimate-conference
An introduction to cardiothoracic ICU. In this 30 minute interview with Heather Low, an intensivist with an interest in CT ICU, we cover a few topics of interest to those who are new to, or want to know more about cardiothoracic intensive care. We discuss what to look out for at the hand over, high risk patients, complications of cardiopulmonary bypass, the hypotensive patient, the patient with a low cardiac index, arrhythmias and intra-aortic balloon pumps.
A summary of where we're up to with glucose control in critically ill patients in 2012, with a look back through the literature of the last decade. A full text article and all the references can be found for free here: http://onlinelibrary.wiley.com/doi/10.1111/j.1445-5994.2011.02631.x/pdf
A summary of where we're up to with glucose control in critically ill patients in 2012, with a look back through the literature of the last decade. A full text article and all the references can be found for free here: http://onlinelibrary.wiley.com/doi/10.1111/j.1445-5994.2011.02631.x/pdf
Marianne Chapman is a highly accomplished academic intensivist. She gives a very practical talk on how they actually manange the controversial areas of nutrition at the Royal Adelaide Hospital
Here is the talk and presentation I gave at the 2012 ANZICS CTG meeting in Noosa about a planned trial called ALISAH II. It's a phase III clinical trial investigating concentrated albumin to treat patients with subarachnoid haemorrhage. It currently in the planning phase with a grant application pending.
This is the first of three podcasts on nutrition in ICU, this time by Professor Michael O'Leary. Michael was given the topic "TPN is so boring" - see what you think...
The slides are here: https://docs.google.com/open?id=0B9vT1_AbNNQSTTdVRDFzRHlRdHU5dzB2SjFiTDNhZw
Hergen gives a great no-nonsense spiel on right heart failure. The slides can be watched and downloaded here:
https://docs.google.com/open?id=0B9vT1_AbNNQSMzEzMjc5YWItODJhOS00NjlmLWJkZGQtMmZhNWQyMGM5ODQ4
Celia Bradford gives a brief and superb summary of contrast induced nephropathy. The Prezi presentation she refers to can be found here:
http://prezi.com/t79w4fwm1i_u/renal-protection-should-i-care/
Thanks for all the following for the podcasts - please subscribe on iTunes and leave feedback!
Anthony Holley, an ED physician and Intensivist from Brisbane, discusses the ever popular and controversial topic of Goal Directed Therapy. It's case based, up to date and he's a charismatic speaker.
Craig Hore uses a case to frame a discussion about emergency pacing with both transcutaneous and transvenous methods covered.
Ray Raper briefly summarises his view of PEEP and pressure volume loops. The slides to go with this presentation are available on www.intensivecarenetwork.com
A brief introduction to a forthcoming series of podcasts recorded at Roger Harris' Bedside Critical Care Conference, 2011.
Roger Harris explains what Kingscliff is all about, who it is for, why it's so good and about his love of disco and didgeridoo.
David Collins gives an excellent presentation on high frequency oscillatory ventilation. The video to accompany this is available here: http://vimeo.com/26915224
Try to work out what your differential would be and how you would investigate and manage this case.
A case based discussion on the different types of shock encountered in ICU and how shock is diagnosed
A summary of my experiences at the second and third days of the ESICM.
Links include:
Here is the IMPACT calculator for prognosticating in traumatic brain injury
For the Brain Tissue Oxygen Monitoring in Traumatic Brain Injury (BOOST 2) go here
For Simon Finfer's talk on the DECRA study click here
The Girault paper: Noninvasive Ventilation and Weaning in Patients with Chronic Hypercapnic Respiratory Failure
For lung ultrasound, you should look at both the Bouhamed paper and the Sartori paper, both here in fulltext for free.
There are a few lung ultrasound videos out there too, like this one
The BLUE protocol is here
Brain trauma foundation guidelines are here
Free fulltext of ECASS III is here
Martin Smith on intracerebral haemorrhage is all summarised here
A good summary of treating refractory status epilepticus is here
Some good neuro papers from the last year:
- Cerebral tissue oxygenation measured by two different probes: challenges and interpretation
- For the paper on measuring brain temperature with MRI spectroscopy, go here
- Ultrasound of the optic nerve sheath to estimate ICP is here
- Invasive and noninvasive assessment of cerebral oxygenation in patients with severe traumatic brain injury
- This is probably a more useful paper on the risk factors for delirium after cardiac surgery
- The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest
- Also see our presentation on this topic here
Top haemodynamic papers:
- Here is an older paper on using IVC diameter for volume responsiveness, and here is the paper Alex Mebezza referred to
- Comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial
- Effects of fluids on microvascular perfusion in patients with severe sepsis
Top Mechanical ventilation papers:
- Non-invasive ventilation in postoperative patients: a systematic review
- Comparison of patient–ventilator interfaces based on their computerized effective dead space
- Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU
- Post-traumatic stress disorder after weaning from prolonged mechanical ventilation
Top ICU infection/micro papers from the last year:
- Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection
- Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis
- Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study
- Intrapleural use of tissue plasminogen activator and DNase in pleural infection
Best of metabolic and sepsis articles last year:
- Impact of hypoxic hepatitis on mortality in the intensive care unit
- Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness
On TEGs and ROTEM: * Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy * A Cochrane review is here
A description of some of the presentations I attended on the first day of this year's ESICM conference in Berlin.
Here are links to some of the material discussed in this Podcast:
- For the WHO Malaria Guidelines, look here
- For an article on paroxysmal sympathetic hyperactivity, go here
- For more about VAP, there's this, and for prevention, look here.
- Here is the JAMA paper on hydrocortisone in multi-trauma patients
- For review on NAVA look here.
- Here is the key Subarachnoid Haemorrhage paper: Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference
An interview with Professor Richard Lee discussing the role of intensive care specialsits now and in the future.
A podcast on the acute management of spinal cord injury from an Australian Emergency Department and intensive Care perspective.
A case-based podcast on the acute management of intra-cerebral haemorrhage by Oliver Flower, an intensive care specialist from Sydney. It accompanies a recent review article:
Flower O, Smith M.
The acute management of intracerebral hemorrhage.
Curr Opin Crit Care. 2011 Apr;17(2):106-14.