We love a jolly @StEmlyns and true to form we were off to the UK Intensive Care Society State of the Art conference this week in Birmingham. This is always a very impressive melting pot of clinical and academic experts in critical care, trauma and applied sciences. They struck a nice balance this year on acute care and rehabilitation medicine as well. Lots for everyone. Here’s what we got up to.
Sonography was the name of the pre-course game and the team put on a good day demystifying the new UK critical care approach to clinical ultrasound, rebranded recently as Focussed UltraSound for Intensive Care (FUSIC). This now split into heart, lung, abdomen, vascular, DVT, haemodynamics and even focussed TOE accreditation. There is lots of guidance online and some regions have developed supporting procedural care videos which are worth a look.
The workshops had lots of hands-on time, some great experts, some good procedural phantoms and some excellent pathology stations. All very good to learn fresh or dust off the cobwebs and benchmark yourself. They also had some more advanced stuff which stimulated discussion, including a TOE phantom (which was ace) and a variety of modern US machines with inbuilt software allowing rapid estimation of EF and pressure gradients. Good to try out.
Top tip from Dan here – I was pointed towards some of the excellent videos by Sharon Kay, which having looked at briefly I can highly recommend.
A pumping presentation opened the ceremony and plenary, to a background of Take That and The Greatest Day. We had not expected this to be the greatest day of my life if we’re completely honest, but we’re always happy to be proven wrong…
We heard first about workforce challenges; in particular the present and future horizon. A diverse multidisciplinary panel did some deep diving and discussed a number of issues.
There was discussion about embedding of critical care transfer services and enhanced care within an NHSE clinical framework, ensuring adequate levels of training, governance and development. There was also some discussion about digital support for tertiary specialist critical care services, modelling some of the recent ECMO experiences during the pandemic. This moved into sustainable careers and a discussion about how we keep experienced people in clinical facing roles. Ensuring advanced career pathways for the whole MDT? Appropriate job planning and flexibility for all? Increasing remuneration? Easy to talk about, harder to enact change, but some good points made for reflection. The FICM sustainable careers document (pdf) and optional skills frameworks underpin some of this. Are the AHPs on your unit job planned, with opportunity to develop their 4 pillars of advanced practice? Do you allow flexibility in job planning for medical staff? How do you reduce attrition? We came on to education but fell back to the same issues – we all need to look after ourselves, we all need opportunities to flourish, we all need supervision and support, we all need to recognise our worth.
But if everyone needs to flourish, what about competition for training/procedural care opportunities? Spicy. We heard the distant rumble of social media thunder and we were all reminded of some of the contentious issues here. We heard about a recent statement from the RCOA on this with regard to Anaesthetic Associates that provides an interesting and balanced perspective. We talked about the enduring challenges of SAS education and training alongside deanery trainees. We heard about the complementary nature of ICU medical and AHP training – education can be overlapping and mutually supportive. And we heard a bold statement from a panel member, that if you have a problem with this issue on your unit, you are probably doing something wrong. When asked directly about what we need in the future, here were some of the take homes:
- Increased capacity for CCU care, to remove the gatekeeper stress
- Whole unit accountability for education
- A renewed focus on wellbeing
- Protection of AHP roles and further integration of the developing and diverse workforce
Nothing brand new here, but some interesting perspectives on thorny issues and a good parallel chat online. Nice to see ICS grasping the nettle and great to see a large diverse panel being given the opportunity to air their opinions.
Next, ICS and the physiological society coalesce to wander through the respiratory and ventilatory minefield. We were taken through a case of breathlessness. We do like these interactive, poll based, decision making cases. There were some nice slides, mixed presentation styles and interweaving threads summarised by many on twitter. The overarching points were about our understanding of physiology in the symptoms and aetiology of respiratory failure, and how we should probably be a bit more honest about what we don’t know and when things don’t line up. There was a pitch to learn more from animal physiology and a few questions around the importance of explaining things to patients. Overall, this was a nice exploratory session unpicking a complex topic that we often insult by labelling as type 1 respiratory failure.
After lunch it was time for the streams to start. Over in Building Tomorrow’s ICU, we heard about the guidance that is currently out there on designing ICUs. It’s surprisingly patient light with only one reference of the word ‘patient’ at all, and given they are at the centre of everything we do, maybe we should think about more about how we can tailor our units to their needs, whilst still finding that balance to provide excellent hospital care. It was fascinating to hear from an architect about how they think about space and movement when designing buildings, and how this could help in a hospital environment too. The key messages were to get involved early with planning (if you’re lucky enough to be getting a new department!) and ensure that you highlight things that are must-haves for your team and your patients to ensure they make it into the finished product.
Livers next and we were talked through the new EASL guidelines (hot off the press) on acute on chronic liver failure. We recapped various scores to help guide clinical assessment in this situation, including MELD sodium, CLIF SOFA, CLIF C OF score, CLIF ACLF and CLIF AD score. We were reminded of the importance of hunting down reversible precipitants – infection, bleeding alcohol, viruses, drugs and the importance of escalating through local gastro, hepatology and transplant centre services.
We also heard from several liver intensivists regarding the improved outcomes from even ACLF – >50% patients appear to survive the initial ICU admission for example, according to pooled data. However, this is observational data (likely to introduce some selection bias) and we think the data presented suggests only 25% will be alive at one year. Usual advice is to just be a good intensivist and consider the whole patient when deciding on the appropriateness of admission; but when in doubt, guidelines will advise you to admit for a trial of critical care therapy and prognosticate over the next 3-7 days. They will also support you to withdraw therapy, when your patient has reached >3 organ failures and has a CLIF score >70.
We also thought about how we need to adjust our drug dosing in these patients – a challenge we can all relate to, and definitely those of us with a strong pharmacist presence on our units know how excellent they are when it comes to this. LiverTox is a free online resource accessible through PubMed and whilst there is no dose adjustment guidance here, it does provide information to help you understand the liver toxicity profile of the drugs you are prescribing.
Last, we dipped into delirium and were reminded by Wes Ely that even brief episodes of delirium carry an attributable risk of mortality, and later cognitive decline. Some powerful patient stories were shared and we were given a glimpse of the suffering associated with delirium. We also heard about the powerful strength of feeling related to these experiences, that often persists for many years. Remember this when you go back to your units and we urge you all to spend time at the bedside reducing sedation, reorientating your patients and engaging their family. A few references to refresh your memories and a link to Wes Ely’s delirium focused webpage, if you need them:
We’ve certainly had a great first day, see you tomorrow for day 2!