St Emlyn’s were on tour again this week, and I was lucky enough to attend the yearly UK Intensive Care Society State of the Art (ICSSOA) 2017 Conference in Liverpool. This is always a great get together for UK and international intensivists, increasingly joined by emergency physicians, prehospital emergency physicians and acute medics. I couldn’t make the whole 3 days (some of us have to work don’t you know) but there was loads to get stuck into in the first 2, so rather than ramble on I shall get to it. Bear in mind that the social media team for #ICSSOA2017 have been writing daily blogs as well, so have a look there for a different take.
I suppose a first point to make is that this was the first ICSSOA for a long time outside of East London. That was a nice touch to try and open up this excellent meeting to those folks who don’t enjoy a trip to the capital, and also to showcase the great city of Liverpool to those who don’t often visit. The ACC is a record breaking venue right on the River Mersey with a great view of the docks and access to Liverpool city centre. I lost count of the number of people who commented on how nice it was to have the conference in a different location – but I’m a Northerner and so perhaps that breeds selection bias in the comments…
Once in, a nice opener greeting me straight off the escalator was the introduction of ‘pop up’ plenary sessions. These included Anna Batchelor on GIRFT and how some of these lessons are applicable to critical care, and Paul young on upcoming ANZICS work. There was also a nicely dramatic opening sequence in the main auditorium, with a robotic demonstration. The blue eyes didn’t fool me though ….
— Dan Horner (@ExRCEMprof) December 4, 2017
The plenary then began with @armycritcare talking about the clinical care of patients after a terrorist incident. This was a general recap but also pearls and pitfalls. Andy has released a series of tweets to go with his talk that highlight the recent evidence better than I could – have a look at his thread and I’m sure you’ll discover something new. Take home points for me were the early consideration of WHOLE BODY (not Vertex to symphysis) CT imaging to accurately identify shrapnel injuries in limbs at an early stage, which can cause long term rehab issues if left in situ inappropriately, and a reminder that any bullet track in a cavity means this cavity is contaminated – definitive surgery should be delayed until the extent of necrosis has been delineated and the cavity washed out thoroughly. He also covered the media – including what to do with the press, celebrity patients and when the royals want to visit immediately… Bob Winter referred to the handing of information to the press as ‘feeding the beast’ at a later stage of the conference. I love Bob.
A pro/con debate then followed on early mobilisation during critical illness. Some great points made about the benefits of rehab and the increasing ability to exercise and mobilise patients with artificial airways on sedation, acting as a powerful positive visual stimulus for patients, relatives and staff. However, some great counterarguments were made to this, along the tenet of ‘if I’m sick let me rest’. Paul Young highlighted many flaws with the current evidence base and made a compelling argument for critical illness myopathy and neuropathy as an inflammatory disorder, rather than one of muscle wasting. How does standing up help this? Just because people sometimes get better when we mobilise them, it does not necessarily mean it is the mobilisation that is helping. Add to this the risks of early mobilisation in lightly sedated patients, including accidental device removal, falls and exhaustion. Like always, Paul called for more randomised controlled trial data and got in a plug for the ANZICS TEAM trial which I think will offer some good information here. Have a look at the hyperlink which covers a lot of the background references and have a think about the way you manage patients in your units, and whether you do it that way for them, or for you….
A debate followed on national standards, cohorting, major units and the working pattern of a small district general hospital critical care unit. Have a read of the GPICS document if you haven’t already; it sets out standards for modern intensive care medicine. It has it’s detractors but is an excellent aspirational document of where we should all see ourselves if we want to provide high quality evidence based critical care, as far as the literature and expert opinion allow. There was also a whip on stage. I have no words.
That afternoon I treated myself to the robotics session. I have to confess I was less impressed with this one – it gave me a good sense check as to where modern robotics is at present and what we can expect in the next 5 years. But the models on display (including PEPPER) were very much diagnostic programs in a nice box, which took a bit of time to process verbal information requests and often went in the wrong direction. Rather than the robots themselves, the saving grace of this session was the excellent delegate questions that followed. Why didn’t the robot reach out and hold the hand of that patient in the demonstration? Why would I spend 20,000 Euro’s on a robot when I could spend it on a person (carer)? Why would you introduce a robot companion to a patient in hospital, then take it away on discharge? And lastly, to the makers, have you ever assaulted a robot? I think we all knew the answer to that one.
Later in the afternoon we had an update on management of acute pulmonary embolism and acute severe pancreatitis. This latter session reminded us that patients should probably be allowed to eat and drink when they want and opened my eyes to the wonders of endoscopic retrograde pancreatectomy, including the recent Lancet TENSION study. Not something I have considered before as an option, given I don’t work in a tertiary hepatobiliary centre. However we do see a fair bit of acute severe pancreatitis and the speaker certainly made me want to read these studies and raise the question about endoscopic therapy in future cases of necrotising pancreatitis. I am not sure the data is compelling, but certainly helpful to be aware of the options.
First up for me was a great evidence based summary of where we are with restrictive and liberal transfusion thresholds in critical care, presented by Tim Walsh from Edinburgh. There have been some great studies on this recently, including TRICS in cardiac surgery, TRIBE for burns, and a recent meta-analysis of GI bleeding patients. All these seem to support a restrictive strategy as using less blood products to obtain the same clinical outcomes, in keeping with previous trials on general critical care patients. A few controversial areas were highlighted, including pre-existing cardiovascular disease and those with acute coronary syndrome – the MINT trial is planned to provide more information here but at present Tim seems to practice a more liberal threshold of >80g/dL in this group, based on a supporting BMJ publication from his research group this year. Thresholds in traumatic brain injury also continue to be debated. The HEMOTION trial looks set to address this and should hopefully start recruiting next year in the UK.
Trauma followed, with Caroline Leech, Peter Brindley and Gareth Davies waxing lyrical on PHEM, resuscitation ‘hacks’, and why people die from trauma respectively. This was an interesting update and conveyed a lot of the front door complexity of trauma well, to a room largely comprised of ‘back door’ delegates. A few interesting pearls – double barrelled resuscitation and the use of 2 IO devices in a single bone appears feasible and reliable. Gareth highlighted the increasing awareness of impact brain apnoea and the questions around cause of death in some shocked patients who don’t seem to have any radiological or post mortem evidence of haemorrhage. Caroline highlighted very well the challenges of on scene decision making in PHEM and that it’s not all about drones and REBOA and ketamine.
More on trauma later that morning with a good synopsis of state of the art management for burns patients and management of the ventilated spinal cord injury patient. A snapshot of the take home messages from this last talk is below – we struggle at my neurosciences centre with weaning and progression in these patients clinically sometimes and it can feel like we are in a real limbo of too sick for rehab, too well for ICU. Nice to hear thoughts from the clinical leaders at the highly specialised units.
— Scott H (@scott_amh) December 5, 2017
Gold medal presentations for me then, and in particular a first look at the results from the TROPICCAL study that many of us recruited to. Annmarie and the group from Edinburgh have done great work here, publishing twice already on the hypothesis that limitations in oxygen delivery in critically ill patients can cause acute myocardial injury and may be potentially modifiable in ways other than treating the cause of illness. Some raw stats from her project which recruited over 250 critically ill patients across multiple sites; over 70% of our admissions with have a peak high sensitivity troponin elevated above the sex adjusted normal threshold. When correlated with ECG abnormalities suggestive of ischaemia (reported by cardiologists blinded to troponin results) it would appear that roughly a quarter of our population also meet the criteria for the universal definition of acute myocardial infarction. Should we screen for this routinely as it can often be silent? Can we do anything about this when recognised? Should we change our physiological targets or our transfusion threshold? Interesting stuff and expect TROPICCAL to be published later in 2018. A lot of major incident stuff followed, much of which was explicitly not for social media, as reports are still being processed by the department of health and others. However it was a really interesting insight into how Manchester and London coped with recent events, the aftermath including impact on elective work and the emotional impact on staff. Lots of lessons from a shared panel discussion later that day with Manchester, London and Nice represented well. Also lots of plea’s to familiarise yourself with the local major incident plan and plan to prepare. What’s the old adage, ‘fail to prepare….etc….’
Last thing I went to in the afternoon was a multidisciplinary session on tracheostomy management. First up a very good ENT surgeon highlighting the longer term issues of endotracheal intubation and the problems that can result from surgical tracheostomies with large windows. We were treated to a variety of videos clearly demonstrating vocal cord paralysis, tracheal webs, subglottilc stenosis, tracheal stenosis and the myriad of surgical techniques available to try and manage these complex pathologies. Certainly food for thought and made me personally very keen to try and push for direct airway imaging in patients who are struggling to extubate or wean for slightly unclear reasons. Brendan McGrath then followed, highlighting much of the great work done through the National Tracheostomy Safety Project including the accessible algorithms and further on the collaborative information sharing through the Global Tracheostomy collaborative. There followed some interesting questions about the algorithm which is apparently due for revision over the next 12 months. In particular someone during question time highlighted a great acronym for dealing with the initial plethora of interventions prior to removal of the tube. I think this should be credited to Reading Critical Care unit, who are apparently teaching CISCO to all their trainees at the start of any tracheostomy emergency once liberal oxygen has been applied to all the relevant areas:
C – check for air movement at the mouth and stoma and get a Mapleson C circuit ready
I – inner tube – remove and check for blockages
S – Can you pass a suction catheter down the tracheostomy?
C – Cuff down – does this improve ventilation or ability to pass a suction catheter?
O – OUT it comes, if none of the above have led to clinical improvement.
That was it for me. I would have liked to stay for the third day and as always this was a great opportunity to hear about national perspectives on common issues, and to catch up with friends and colleagues. No doubt there will be other blogs and podcasts to come, but in the meantime catch up with some amazing summaries from Aoife Abbey aka @whistlingdixie4 on her twitter feed, and now on the excellent Propofology blog. These are amazing.
— Aoife Abbey (@WhistlingDixie4) December 5, 2017
There were lots of conference gems and I would encourage all who work in acute care to think about this conference for reliable CPD. The multiple tracks offer great value and broad interest. Also the organisers keep on changing things, which I really like. The State of the Art has been going a long time; they are clearly keen to keep it fresh and I think this comes across very well.