Neurocritical care debate, discussion and overall goodness this month, in the form of a conference. This time at least it’s local and the St Emlyns team are off to Manchester for the 50th Annual Scientific Conference of the NeuroAnaesthesia Society of Great Britain and Ireland (NASGBI). If you thought that was a mouthful then during the meeting they voted themselves to become the NeuroAnaesthesia and Critical Care Society of Great Britain and Ireland (NACCSGBI). Long live a good acronym……
Anyway, a fantastic couple of days with great keynote speakers, invigorating debates and a good display of national work. The local organisers did a fantastic job with the venue and main track, but more importantly if this wasn’t enough they also ran a parallel day for non-anaesthetists celebrating all things traumatic and neurosurgical. Less important than the content here is the coming together of tribes. We all know that multidisciplinary input is key to the journey of traumatic brain injury and this felt like real recognition and understanding of the additional clinical roles outside of theatre. Also a great networking opportunity for emergency physicians, intensivists, neurosurgeons and anaesthetists; altogether a very valuable exercise.
No conference can be summed up in a single post, but there were a few particularly interesting topics that found their way to the twittersphere and garnered attention. These were our favourites:
Oli Harrison presented a short survey of consultant anaesthetists on choice of induction agents and post intubation physiological targets for a standardised single hypothetical scenario of a young patient with isolated traumatic brain injury. The results were not quite as cohesive as may have been expected. Propofol topped the chart at 51% for induction, thiopentone 33% and only 2% choosing ketamine. Post induction targets were even more interesting – less than 50% were interested in a strict ETCo2 of 4 to 4.5KpA and just over 50% wanted to keep the MAP >80. This being despite recent NICE guidance. Tentative suggestions as per the conclusion that standardised operating procedures for RSI in the head injured patient may be of benefit sparked debate on twitter:
This discussion concluded with the idea of a standard operating ‘guideline’ depicting safest practice while recognising and encouraging expert adaptation on a per patient basis. However, I’m still not sure this sits right with me. I recognise that education and individual clinical assessments are key to delivery of safe practical care to the critically ill patient. But I think there is also little merit in having a guideline that offers unclear and limited guidance. Local attempts to discuss standardised induction regimes have met with harsh criticism recently (Ed- and not just in your world Dan, we’ve experienced this too) so people obviously feel strongly about this. But I think the debate needs to continue – education and adoption of best practice will take time; until then, should those of us with more critical care experience not be collaborating to propose a baseline ‘safest level of care’ through induction algorithims?
My next favourite was a combination of talks on fatigue and situational awareness, facilitated by an air traffic controller (have a look at this if you’re wondering what air traffic control has to do with cognitive overload) and a member of the RCOA working party on fatigue in anaesthesia. A good document and worth a read on your next night shift. We were encouraged to identify the difference between system 1 and system 2 by a simple maths puzzle, with a bat and a ball costing £1.10. If the bat costs £1 more than the ball, how much does the ball cost? System 1 took hold of me – 10p 10p 10p 10p 10p 10p 10p. After wrestling control of my own brain back I worked it out eventually but this always highlights a point for me. The benefits of understanding fatigue and situational awareness are primarily about understanding what these situations will do to you personally – such that you can recognise, adapt and engage others when you feel you are not firing on all cylinders. And did you know that if you are awake and operational for 21 hours it is comparable to being over the drink drive limit for alcohol in the UK? The speakers urged us to all to end the ‘macho’ culture of back to back shifts/opting out of the European working time directive. There is no doubt that we may sometimes do our patients a disservice by trying to persevere in exhaustion. This martydom should be discouraged at the top, and from the top down.
After this, a debate about specialist neurointensive care units versus neuro patients on a general unit. Interesting arguments. The proposer for specialist care cited disease specific knowledge of highly trained neurosciences nursing staff as the key to benefit in these complex patients. Maybe a subtle way of celebrating national nursing day? The opposer had slyly performed a round telephone survey of all UK specialist neurocritical care units previous to the debate and had current data on the general ICU measures that they could and could not perform. There was some quibbling in the questions, but the take home from this was powerful – On site ability to deliver polytrauma care, critical care echocardiography and citrate based renal replacement therapy were rare within specialist centres. Very rare. My take home? Stick me on a good general unit with neurosurgical input any day of the week please…..
Brendan McGrath from the Global tracheostomy initiative talked about the big fuss over a small hole – I cannot commend this work highly enough and would urge you to look at the resources and training packages provided online if you have not already. It will save your (patients) life one day…. James Palmer talked about NAP5 and relevance to neuroanaesthesia/critical care. One important message I got from this was about the real terror of awareness being the fact that no-one is talking to you or understands that there is a problem. There were compelling anecdotal stories of patients accidently paralysed who had little psychological sequelae, attributed largely to the fact that the physician responsible had immediately reacted – “I know what is happening and I can fix it immediately”. Sobering stuff, but a good reminder of the fact that all our patients need kindness, humanity and understanding; even the ones who are sedated, supposedly comatose or deemed to be unaware.
Too much other great stuff to fit on the page. But suffice to say it was an excellent event and a great collaborative event. Have you considered putting on a local multi-tribal meeting? You may find it is to everyone’s benefit. Including your patients.
Best wishes all
PS – The Ed enjoyed Steve Peters talk from Chimp Management. I now understand the St.Emlyn’s team to resemble a troop (a rather nice troop of course).