ICS #SOA23 – Day 3

Final day here at the Intensive Care Society State of the Art Congress, and although it’s a shorter day there is still a huge amount of variety on the menu, so we’re here to get started and get some knowledge. If you want to check out what we learnt on the previous two days, you can have a read of the day 1 blog here, and the day 2 blog here, so check those out and then come back for the finale, we’ll wait.

Right, you’re back, let’s go!

Neuro

A spot of neurosciences to wake us all up in the morning and we heard first from David Menon about the breadth and depth of findings from the CENTER-TBI study. Lots and lots of evidence and insight from this collaborative work. A few highlights; mild TBI is the largest burden of TBI at present, accounting for 68% of all relevant attendances in this study; CCU casemix is changing and guideline compliance is imperfect; 26% ICU TBI admissions are now over 65 and >10% have severe systemic disease, with a similar proportion taking preinjury anticoagulation.

What about advanced airway management and TBI? This paper highlights some interesting points, including potentially improved outcomes with earlier intubation in hospitalised patients with decreasing GCS and with prehospital intubation in those TBI patients with extracranial injury. 

What about high intensity treatments? This paper showed substantial variation in use and raises questions about whether we believe the evidence we have, whether we follow the guidelines, and how we standardise our care.

Fluid balance? This paper suggests we should aim for euvolaemia in TBI patients. Of course we should. Just a shame that we don’t really know what this means or how to measure it.

Management of PaCO2? This paper again shows variable practice, but also suggests that if you have ICP monitoring you may be more likely to blow the bellows harder. Check yourself and remember the Seattle Consensus guidelines.

Hyperoxia? This paper suggests it is bad in brain injury. Like it is for everything else.

VTE prophylaxis? This paper suggests variable practice but an overall association with improved outcomes in those receiving pharmacological prophylaxis. No real evidence that prophylaxis worsens bleeding here either, even when started at a median of 55h. More evidence required to navigate a widespread change in practice though, and the TOP-TBI study should deliver this for the UK over the next 5 years. 

Overall, mortality in the CCU cohort was 21%, survival with GOSE <5 of 40% and survival with incomplete recovery around 80%. A stark reminder of the severity of this disease. Are we doing better than previous? Perhaps with regard to mortality but likely at the expense of producing more highly disabled survivors. Take home message – the ICU standard – less is more when it comes to fluid, oxygen and ventilation.

The holy grail – can we predict outcome better? We heard about MRI, biomarkers, biomarkers that may predict who needs MRI and some other interesting work, but unfortunately nothing that could help guide decision making up front. Again, we are likely faced with the ‘trial of ICU’ in cases of uncertainty to help prognosticate, which we have heard in other sessions this week. A quick plug here for the guidelines on management of devastating brain injury, which are very helpful and have changed practice.

Speaking of prognostication, coma was next and we were reminded of some of the ethical challenges. A warning around using simplistic scoring systems to predict mortality and deliver self-fulfilling prophecies. We were also introduced to the curing coma campaign, looking to endotype patients, produce more evidence and support families and clinicians to make decisions in these tricky cases. More at https://www.curingcoma.org.

Early survey data from this group suggests we already disagree on the definition of coma and provide variable care. Some interesting thoughts and insights here including a lovely phrase ‘the best monitor is the clinical examination’, but little discussion on the additional resource need, emotional challenges and suffering associated with futile care. Last, a very interesting slide and discussion on neurorehabilitation – another highlight that functional outcome after brain injury/subarachnoid haemorrhage can improve AFTER 6 months, bringing the GOSE as a trial outcome measure into real question and implying that we should be judicious in our prognostication, even after several months of hospital care with limited evidence of recovery. Interesting. If you haven’t read the RCP stuff around prolonged disorders of consciousness, it’s probably worth some of your time.

Then a pro-con debate on vasospasm, delayed neurological deficit and delayed cerebral ischaemia following subarachnoid haemorrhage.  Lots of slightly weak data presented here to support physiological arguments, but overall another reminder that we have very little scientific evidence to support our current practice in managing DCI. If you don’t believe me, take a look at the most recent national guidelines and pay particular attention to some of the evidence grades supporting common recommendations. Food for thought?

A Greener ICU

We didn’t make it to the green stream but saw some great tweets coming out of there. ICS have committed to making the recording of this stream free to watch for everyone, so even if you didn’t come, you can still check it out, we’re sure it will be well worth a look from the concurrent tweets! We’ll try to keep an eye for a link when it’s available and stick it in here.

Ethics and Law

Next up we were at the ethics and law stream, starting off with a talk on recent case studies from the court of protection. We heard about several cases that had gone in front of the court, including some fairly high profile ones that you’ll have no doubt seen in the news. We also heard about how the media portrays death – as something that is always pleasant, peaceful, and quick, which we all is know is far from reality for many of our patients. Does this fuel the lack of understanding that some families have around what death is and how it happens, leading to the conflict we have all seen recently in the media around some of these high-profile cases, and sometimes leading to death threats or violence against healthcare workers. Does society as a whole need better education around death in order to improve their trust in the medical profession for their relatives at the end of life?

Dale Gardiner spoke about the diagnosis of death by neurological criteria and some of the history about how this has been embedded in practice and changed through the years. Our diagnosis criteria have evolved because we want to ensure that it is the safest it can be. The future of death by neurological criteria looks towards moving the time of death to the second test, incorporating red flags into the preconditions and potentially adopting the ‘world’ end PaCO2 target of 8.0kPa.

After a spot of lunch it was time for the closing plenary. The organisers took time to praise the volume and quality of abstracts submitted to the conference, (and we as the audience gave them a big round of applause for putting on such a great conference!) before pressing on with the awards ceremony.

Here is a list of all the award winners – congratulations to all of them, we had the fortune of seeing a few of these presentations, and the awards were definitely well deserved.

The Cauldron winner – Cat Anderson with “Enteral nutrition in critical care – there must be another ‘whey’”
The Gold Medal winner – Zoeb Jiwaji with “Targeting astrocytes to reduce critical illness associated brain vulnerability”
Ultrasound Ninja winner – Ketan Champaneri with “Mitral valve prolapse presenting as a missed myocardial infarction”
Prize for the oral platform presentation – Rachel Saunders with “Review of the medical support worker programme in intensive care”
Critical Care Tales winner – Rebecca Hetherington and Brenna Fossey with “Trach to basics”
E-poster winner – Delphi Henderson with “Out of hospital cardiac arrest”
TRIC Network competition winner – Tom McClelland with “Identification of difficult airways on critical care”
Joint ICS and NIHR award winners – Nikitas Nikitas and Brendan Sloan

We then heard from a panel debate on the topic of ICU rehabilitation – is it dead? Paul Young and his team published a paper last year on early active mobilisation during mechanical ventilation in critical care with their conclusions that increasing this above usual care did not significantly improve patient outcomes such as length of stay or mortality. It was reported in the New Zealand media (and we saw a video of this at the conference) that this could be a huge saving for health services across the globe in terms of savings that could be made in time and workforce. There were some possible confounders with the study, such as the usual care group still receiving a high amount of mobilisation time compared with previous studies, but this blog is a conference review, not a journal club, so go read the paper yourself and we’ll move swiftly on!

This provided the starting point for the debate with a great panel arguing for and against the motion that rehabilitation is dead. Clearly it was a bit tongue in cheek as none of the panel members thought this was truly the case, but there were some great learning points for us to take home.

We need to get better at identifying what patients rehabilitation needs are. The Post-ICU Presentation Screen PICUPS tool (pdf) can help with this as a brief functional screening tool designed for use in patients being stepped down from critical care settings. It is designed to inform the immediate plan for care on stepdown, identify problems that might need a more detailed evaluation, and be used to prescribe their rehabilitation. Using the tool can also help to identify gaps in your service and demand for the future.

Our patients have significant multidisciplinary needs which it can be tough to meet with staffing and funding problems and this can impact on their life and recovery. The Faculty of Intensive Care Medicine have put together a working group to look into this and created a guide for developing and delivering aftercare services for critically ill patients, in the form of the Life After Critical Illness document which you can look at here.

We heard from many members of the audience about their own views and stories, which was a fantastic way to head the conference to a close. We can support our patients, their loved ones, and their families with us on their journey through critical care and beyond. And we also have to try to get our patients back to where they want, not to where we want.

Finally, we found out about the call to action from the WHO with Rehabilitation 2030. They have created 10 key points to improve rehab over the next few years, including strengthening leadership and political support for rehabilitation, incorporating it into universal health coverage, ensuring equity by establishing links between countries of different incomes, and boosting research capacity, We need more research into rehabilitation, using data, economics, and patient stories to influence those who have the ability to make a change. We all need to be a #RehabLegend.

We’ve had a great time, learnt lots, and hopefully you have too. ICS SOA 2024 will be in Liverpool at the ACC from 18-20 June 2024. We hope we can make it along and to see you there!

vb
Dan and Chris