ICS #SOA23 – Day 2

We’re back for the second day of the Intensive Care Society Sate of the Art Congress here in Birmingham! Yesterday was great and we learnt a lot with loads of things to think about for our own practice back home. It’s an early start at 0800 but we dragged ourselves out of bed for the greater good. You can check out what we took away from day one here on yesterday’s blog, and here is day two, starting with the papers from the year in review:

A year in review – kidneys:

Embedding AKI alerts in electronic medical records. Does it help? Perhaps. This paper randomised patients to an automated alert regarding key nephrotoxic drugs, such as NSAIDs, RAASI and PPIs. The danger word ‘trend’ was mentioned a few times, but in defence, the use of AKI alerts almost reached the level of statistical significance, with a RR 0.92, 0.83 – 1.01, p = 0.09 for a composite primary outcome, including RRT and death. Interestingly, when examining the impact of this complex intervention on cessation of nephrotoxic meds, the control group stopped pretty much as many NSAIDS as the alert group. Hawthorne effect or just good medical practice? Whatever you think of the outcomes, the paper was a nice example of embedding research within an electronic health record.

Then onto STARRT-AKI – does early RRT in critically ill patients decrease mortality? In general,  no, it does not. More importantly,  if you have chronic renal disease, you appear even less likely to benefit – this subgroup analysis suggests a higher rate of 90 day dependence on RRT in such patients without improvements in survival. More subgroup analyses of STARRT-AKI and these authors have put paid to the idea that RRT helps with fluid removal. We found this interesting and it generated some audience questions – why can’t we sort fluid balance properly? The answer proposed was that RRT does not remove interstitial fluid, therefore will never scratch the real itch. Maybe we just need to concentrate on helping patients get better and restore their own glycocalyx.  

It wouldn’t be a renal ICU session if we didn’t talk about novel biomarkers for AKI, so here was todays – soluble urokinase activity Plasminogen activator receptor., or SUPAR for short.  

A later paper suggests this one may correlate with need for RRT when you add creatinine, with an excellent AUC of around 0.86. We’ve heard that before, and this one looks well short of implementation studies within general settings, therefore generalisability remains questionable. But still, a new learning point and one to keep an eye on over the next few years.  

Last, an interesting but small study suggesting that our conventional creatinine measurements may over-estimate eGFR in our recovering sarcopenic patients on critical care; cystatin C was more accurate in this cohort when compared against reference standard testing. We’ve heard lots about cystatin C over the years. Do you use it? Does it help?

– the gut:

Critically ill patients lose a third of their muscle mass during the first 10 days, and at 6 months post discharge the vast majority continue to have significant issues. We put a lot of this down to nutrition. How can we tackle this issue?

Should we give more protein – the EFFORT-PROTEIN study would suggest not, and that this may actually harm some subgroups (high SOFA score or AKI).

Should we give less protein or calorie content? NUTRIREA-3 has recently published and concluded that this doesn’t seem to help either. No mortality difference was seen between groups randomised between low dose calorie and protein delivery. The authors saw higher rates of vomiting and complications in the standard care arm and longer delays to ICU discharge readiness, so the take home advice was that lower intake regimens during the first 7 days appear to be equally effective and may be preferable.

What about feeding right up to the point of extubation? Can we do away with fasting prior to airway instrumentation in the critically ill? A slightly different question, but fun to think about all the same. This non-inferiority trial would suggest that we can consider such a strategy, as the reintubation rate met the criterion for NI. That might need some buy in though and we weren’t sure the evidence presented here was definitive.

– the airway:

Has video officially killed direct laryngoscopy? We heard about the recently published DEVICE trial, a subgroup of the Cochrane review on video laryngoscopy outside the theatre environment, a subgroup analysis of the INTUBE study looking at induction agents, we did a poll (50:50 for VL:DL!!) and we heard about the Bath experience of using primary VL for the last decade. We have covered a lot of this evidence in previous blogs here and here, so we won’t dwell again too long. But although we are not sure DL is dead, and we think that if you are very experienced it probably doesn’t matter what you use, we also think we can now fairly confidently say that VL is winning. The summary graphics from the DEVICE trial are probably the most convincing bits of evidence we have seen on this recently and we urge you to have a look at this paper, if you have not already.

You can also have a look at the PUMA recommendations on preventing unrecognised oesophageal intubation if interested – some good points here and worth reflecting on whether you routinely deliver these in all clinical areas.

ABCs of Critical Care

After a quick break the rooms filled up for the main sessions of the conference. First up for Chris was a session on the ABCs of Intensive Care with quick fire 10-minute talks on various topics. If you’re still thinking about fluid status, Prashant Parulekar suggests we’re moving more towards fluid responsiveness, tolerance and overload. A plea for us to use ultrasound early in our patient assessment and not wait until we’ve given three litres with no improvement, and a plug for the VExUS protocol before we moved on to deresuscitation and natriuresis. Jonny Wilkinson introduced the JICS Mix with a combination of furosemide, aminophylline, acetazolamide and spironolactone. We should be thinking more about natriuresis in our patients rather than just diuresis.

It’s key to ensure our patients understand the information we are giving them. There is a huge reading gap between the literature we provide and the national average reading age. We need to get our literature right and readable, and check that patients understand any verbal information they are given too. How can we do this?

• Teach back technique – “I need to make sure I’ve explained this properly, can you tell me how you’re going to explain this to your family when you get home?”
• Chunk and check – little bits of information at a time with repetition and checks
• Simple language – we’re not talking to our colleagues and it can be too easy in uncomfortable situations to revert back to our comfort zone of medical jargon

Eye care is so easy to overlook on an ICU stay but any eye issues can be life changing for patients moving forward. Prone patients are at increased risk with facial oedema, compression, and risk of eye injury. Good basic eye care, together with a good relationship with your local ophthalmology service is crucial to try to avoid complications that can affect our patients in the long run. We also heard about parenteral nutrition, it’s important to make sure patients have a dietitian assessment, safe access, correct dosing, and good monitoring particularly around fluid balance and glucose control. The final talk around the PIM-COVID study from the TRIC Network which looks at anxiety and depression in patients following critical care admission for Covid is currently in review for publication, so although the results were presented, we can’t post about them here. Needless to say we’ll be keeping a close eye for publication, and taking a good look at the psychological services available in our departments, for which there is a huge unmet need.

ARDS

Meanwhile, Dan was over in ARDS. We heard about the success of REMAP-CAP, the challenges of steroid prescribing in ARDS and the potential future trajectories of care. Of particular note, we heard about CAPE-COD, DEXA-ARDS and the ongoing need for definitive evidence on corticosteroid use in ARDS. The NIHR GUARDS study is now in a protocol development stage and should commence recruitment next year, tackling this question. We also heard about one of the many ICU holy grails – individualised medicine. In the context of ARDS, it does appear like we have technology to stratify phenotypes into hypo and hyperinflammatory profiles and that further platform trials are planned to help us tailor individual treatment plans.

Last in this session, Bronwyn Connelly gave us a nice summary of the evidence on long term outcomes from ARDS. We were initially reminded about the pronounced and protracted levels of physical impairment post disease, the links between weakness and mortality and again the evidence identifying delirium as an independent predictor of cognitive impairment. A lovely overview can be found here, if you can access the NEJM paywall.

Debriefing

Chris – I was off to the debriefing session next and it was honestly one of the best sessions I’ve been to at any conference. Excellent speaking, key messages reinforced with evidence and even a bit of audience polling and participation. It was clear that the presenters had put a lot of thought into the session.

Rather than repeating the messages here (there were many and I wouldn’t do them justice), have a look at the thread I live tweeted as the session went on starting with the tweet below.

Trauma

Trauma for Dan and we heard from Karim Brohi, Ceri Battle and Tobias Gauss. A very nice overview of a complex disease.

First, survivorship and focussed questions on how we improve mortality outcomes in this population. How can we manage the balance between bleeding, coagulopathy and ischaemia?  A nice reminder of recent evidence in the domain, including UK REBOA, PATCH and CRYOSTAT2 trials. Detail from the chief investigator also, about some of the more subtle signals from CRYOSTAT2 including greater benefit when given between 60-90mins (as opposed to super early) and in blunt (rather than penetrating) trauma. Overall messaging to think about dual resuscitation here strategy here, with early prevention of coagulopathy (avoiding crystalloid, balanced resuscitation etc) followed by guided treatment of coagulopathy (TEG or ROTEM based). Also a plea to get on with things, supported by a nice bar chart summarising the fact that even when we get a TEG result within 5-10 minutes, it still takes us 60-90 mins to administer platelets, cryoprecipitate or plasma. We also heard about cardiovascular impairment in the first 48h following trauma as a driver of late trauma deaths. How do we improve this ischaemia shock state without flogging the heart further? A plug for the REWIRE study currently looking at regadenason to improve coronary circulation and a clear message to think hard about how you identify and manage the CVS dysfunction associated with major trauma.

Chest wall injury next. Interesting research landscape here and it will be great to see the results of the ORIF, ESPEAR and others in the future. Prof Battle talked us first through the early approach to chest injury (including risk stratification, monitoring and analgaesic strategy). A plug for the PIC score, for more patient education where feasible and the use of PPV devices for volume expansion and ongoing secretion removal. We then heard about the challenges of ongoing symptoms and the responsibility we have for our late approach to risk stratification, chronic pain and breathing pattern disorders. MDT management is key to success and we need to make sure our patients don’t get lost in the NHS…

TRIC

A whole slot for the Trainee Research in Intensive Care (TRIC) this afternoon, with a brief overview of the network, summary of academic career pathways and then a dragons den presentation for their next project. Great ideas on quantitative monitoring of neuromuscular blockade, proactive identification of difficult airways, socialising non-airway trained doctors and the presence of airway assistants for advanced airway procedures outside a theatre environment. Do you use quantitative neuromuscular monitoring and insist on a ratio of >0.9 prior to extubating your patients? Do you insist on a trained airway assistant for all your advanced airway interventions, as per GPAS, regardless of where you are? Have you seen any evidence that these things actually help or improve patient outcomes? Maybe we should generate some evidence and find out more…

Perioperative

Over in the perioperative stream, we heard that outcomes from major surgery for patients with co-morbidities might be a lot worse than we think. Particularly dementia, cancer and heart failure are independent predictors of poor 2-year outcomes. Do we discuss this with patients? They don’t have surgery just to live for thirty days and we need to make sure they know more about the longer term consequences. There are different ways to have those discussions in order to promote shared decision-making. Using deliberative consultations where the high-risk status of the patient is at the forefront of the discussion, and potential risks and benefits are linked explicably with those high-risk features, can empower the patients to evaluate their current situation more and really weigh up the risks and benefits for all of the options they have. Decision-making in emergency laparotomy is difficult, it’s hyper-acute, complicated, and requires rapid MDT communication. However, 1 in 7 patients regret having major surgery largely due to post-operative complications. Getting conversations about outcomes and futility is so important.

A study trying to quantify futility in patients undergoing emergency laparotomy showed that patients with higher risk of dying were older, nursing home residents, with cardiac and respiratory disease. There was a threefold risk of death in those over 80, or with bowel ischaemia. Lactate >4 and >6 increased the mortality risk by five and ten times respectively. Predictors of futility are not part of our current risk assessment but we have access to them and we can use them. Many risk factors are more common than ever before, but we need to be brave in our conversations with our patients and have these discussions to ensure we are doing the right thing for them. Further work is planned to follow up what happens in those who end up not undergoing emergency laparotomy, as they don’t all die.

Ultrasound Ninja

Finally, to round off the day we were at the ultrasound ninja session watching trainees with an interest in ultrasound present cases with some interesting, novel, or adjunctive uses of ultrasound in their clinical practice. These ranged from the more routine, using echocardiography to identify cardiac tamponade, to the impressive with two litres of pus drained from liver abscesses after bedside ultrasound was used to try to identify a source in a bacteraemic patient, to the never-seen-before with use of ultrasound to identify failure to fully clear secretions from areas of the lung during bronchoscopy.

Overall a few weird and wonderful techniques, but a lot of very nice pictures. We’ll see which presenter is crowned Ultrasound Ninja 2023 on day 3, but we’ll update this here when we know!

Well, that was day 2, a bit of a long day with lots of split streams and of course for anyone at the conference, don’t forget you can watch any talks you missed (or the talks you went to again!) on the online platform for up to six months after the conference ends.

See you for day 3!

vb
Dan and Chris