#ICSSOA2018 DAY 2. St Emlyn’s on tour

The tour continues, and nothing gets me out of bed quicker than a top of the pops countdown. Well done to the program organisers for cunningly putting this first on the agenda to try and encourage delegates to shake off the gluwhein and get back to the learning.

Day 2: Morning

This was a top 5 session presenting papers on nutrition,neuroscience and sepsis. There was a huge amount of information which I can’t convey here, but here are the papers; feel free to hum the top of the pops theme tune to yourself as you count them down. There are good summaries available for many of these at www.thebottomline.org,www.stemlynsblog.org and www.lifeinthefastlane.com:

Nutrition chosen by @ICUnutrition:

  1. The TARGET trial 
  2. The NUTRIREA-2 trial
  3. Nephroprotective trial investigators study
  4. VHPF (Very High Protein Formula)
  5. Metabolic phenotype of skeletal muscle in early critical illness

Respiratory chosen by @camICU_Research:

  1. BREATHE
  2. EOLIA
  3. HIGH
  4. PREVENT
  5. High flow oxygen inbronchiolitis
Check out @whistlingdixie4 for more excellent graphic summaries from the conference.

Neuroscience Studies chosen by @celiabradford

  1. DAWN / DEFUSE 3
  2. Serumneurofilament light chain for prognosis of outcome after cardiac arrest
  3. NOICE – unpublished data from North Shore regarding long term registry follow up of TBI, SAH and ICH – is there a concern that mortality increases further after 6 months? Does this reflect the frailty of this cohort following the index event? Do presenting GCS and WFNS score still correlate with outcomes despite modern care. You’ll have to wait for the publications if you weren’t there….
  4. MIND USA
  5. POLAR

After this it was the radiology masterclass, hosted by the brilliant duo behind Radiopedia. This session was great and reiterates the direction of travel for acute care – if you can learn to interpret these images yourself, then decision making can be expedited and your patients will often benefit . Learning point for me – remember the deep sulcus sign.If you’ve not had a look at the site, then get yourselves there. There was even a quiz. A countdown followed by a quiz? Feels like Christmas already…..

Coffee then, followed by Critical Care Controversies. Should there be more paediatric critical care provision in district general hospitals?Anna Batchelor pointed us in the direction of an ongoing national review that is worth your time.

Should we admit all sick liver patients for a trial of therapy?There was initial talk of how bad we are at prognosticating (again), and suggestion that all recognised scores are invalid in this cohort. Some presentation of ICNARC data followed, suggesting that survival has improved, with resulting ICU mortality <50% since the millennium. However, is ICNARC data just reflective of those we admit after careful decision making? This does not include those who are critically ill who never make it to ICU, as Nazir Lone pointed out during the rebuttal. Doesn’t this just show that we already get it about right? The harms of a ‘trial of therapy’ were also highlighted, including lack of palliation, anxiety and distress for families around a highly interventional death and longer term survival/independence.  A good reference for Nazir’s counterarguments can be found here. There was also a great discussion on the importance of early palliative care referral and anticipatory care planning for those patients who we know are likely to have a poor outcome within the next 5 years, even if theydo survive a critical care stay.

Last up, should we intubate patients without muscle relaxation?  Rob MacSweeny tried to convince us by talking about dogma and the quest for knowledge and progress,via JF Kennedy, Gallileo and Galen. Good points made about the increasing frequency and competency with awake intubation, via fibreoptics and videolaryngoscopy with topicalisation. Bronchoscopy lists and other airway interventions in those receiving non-invasive ventilation were also mentioned. Rob ended with the standard mention about the most dangerous phase in the English language. Alex Psirides for the rebuttal was his usual cynical self, with entertaining use of Betteridge’s law and Graham’s hierarchy of disagreement. He was supported by a timely Cochrane systematic review and editorial in the BJA which presents a compelling case for the use of neuromuscular blockade. As always, the take home is probably not dichotomous and Rob really made me think about where topicalisation and awake intubation might sit in the armamentarium of airway management in the critically ill. Also, a nod from both speakers to the recent DAS endorsed guideline on the topic of emergency airway management, in case you haven’t seen it.       

Day 2: Lunch

It’s not an ICU conference without a tech session. Technology and innovation after an hour’s poster judging for me. Virtual reality first,which reminded me of a recent blog on augmented reality, followed by a short talk on the rise of the machines.Then, on to Mark Forrest talking about immersive high fidelity, in situ simulation.I think this is absolute gold personally; it’s something we do locally when we can and there is now emerging evidence that this is of clinical benefit to both trainee clinicians and patientsMark has done fantastic work with the ATACC course to remind us all what ‘immersive’ actually means and talked about their journey, including the fabled ECMO simulation at the Louvre. Peter Brindley rounded off this session by reminding us eloquently that the space between the ears is the best 6 inches in the human body – we need to retain our humanity, our compassion and our ability to think despite all these technological onslaughts and distractions. There is an editorial on this here and a whole book here if you feel like sitting down with a hot coffee and justifying your technophobia for a few hours…

Day 2: Afternoon

More quick fire updates for me. Turns out we still aren’t really sure when or how to start RRT as per one of the co-investigators for the ongoing STARRT AKItrial. Mention of AKIKI and ELAIN which have both cropped up in our journal clubs recently and are worth a read. STARRT AKI has already recruited >2000 patients and is aiming to close and publish in 2019. Watch this space for more evidence on the topic. Danielle Bear then told us about how she feeds her patients and why.  The 2 main take homes – prescription does not equal delivery; Danielle presented data suggesting that we meet calorie and protein targets <80% of the time during the first 5 days. Second, that less is only more …until you have done too little, and then you realise you have to do more. Recent guidelines were highlighted during this talk, including the ESICM and ESPEN guidelines on nutrition. Good stuff.

The exercise and extreme physiology session was well attended and fascinating. It’s not often that we see the extreme levels of physiology that athletes, climbers and patients can and do achieve through adaptation. A real highlight was Tom Evans and the British Rowing team demonstrating the sort of physiology that would normally mandate a chaplain’s referral rather than an ICU one! A lactate of 34, pH of 6.74 and undetectable bicarb. You can read more about when we did this at St Emlyn’s here, albeit with rather less elite athletes.

Day 2: Other gems

ATACC and the immersive sim centre.

There is almost a conference within a conference on the second floor where the ATACC group have camped out to demonstrate their immersive sim experience. There are three themes running in this area. An immersive sim room which sort of recreates in situ sim in a non-in situ environment. Basically, it’s a temporary room that allows projection onto the walls and a more immersive experience of simulation. Mark Forrest and the team are running sessions there that, if you haven’t already, you should certainly try. @EMManchester joined one group that ended up transferring a patient down in the lift of the building (for real) with lots of lessons learned in packaging and movement. There are also some meet the expert sessions and numerous ultrasound workshops running in the same zone.

Many delegates will have experienced sim centres, some will have experienced in situ sim, but the ATACC group take it to a different level by integrating environment, actors, props and scenarios to deliver intended learning outcomes.You can learn more about ATACC and their course here. Mark also talked about how in situ simulation might be a better way of assessing and maintaining competence in clinical skills. By recording competencies within the simulations a rolling and continuous assessment and record can be made. It’s a really interesting concept which, although some might be worried about confidentiality, would certainly be a better way of assessing competence as compared to annual assessments that are more commonly used in the NHS.

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

Dinner out for me tonight. Hurrah. I intend to drink enough to supress my winter cough. Which is probably mild. But very aggravating.  

Enjoy the dinner if you’re going and be ready for more tomorrow.

Dan @RCEMProf

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Posted by Dan Horner

Dr Daniel Horner BA MBBS MD PgCert MRCP (UK) FRCEM FFICM is an editorial board member on the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine of the Royal College of Emergency Medicine. He is a consultant in Emergency Medicine and Intensive Care at Salford Royal NHS Foundation Trust. He is chair of the national exemplar centre Thrombosis Committee and Regional lead for Injuries and Emergencies on the NIHR Clinical Research Network. He is a Senior clinical lecturer at the University of Manchester and collaborator with the University of Sheffield. You can find him on twitter as @RCEMProf

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