We’re here again at the Intensive Care Society State of the Art Conference. This year for 2019 it’s in Birmingham (possibly the best city in the world, though of course I’m slightly biased having grown up here…)
The conference began after a fantastic piano recital by Ben Attwood with the awarding of honorary societal memberships to Anna Batchelor for her services to education as well as the formation of the ACCP scheme, and Craig Brown for bringing a wealth of physiotherapy experience to ICM. Kathy Rowan was presented with the President’s award particularly for her work around APACHE-2 and the creation of ICNARC. Fantastic role models to learn from.
Alice Roberts and Hugh Montgomery then sat down and discussed genetics, human evolution and how these things can alter not only whether we’re good with heights or are effective mountain climbers, but also how we respond to treatments or even whether we’re more likely to survive an ICU admission with ARDS. Could the future be an intensive care experience based on already known gene sequencing about each patient? Referrals accepted or refused based on mortality statistics for particular genes? An interesting thought for modern intensive care.
The law in England is changing and following in the path of Wales there will be deemed consent for organ donation from spring 2020. There have been concerns in the past about it, together with a lot of “fake news” – the government owning your organs after you die? So it was reassuring to hear from Paul Frost who is a consultant in Wales. Initially he had reservations that conversation would be forceful and the usual compassion would be lost. However, having seen how these human factors have not been lost, he has been won over and is an advocate. One of the first to be involved after the law was passed was Joanna Duckworth, who left few dry eyes in the room after telling us how her husband Scott helped others with the gift of organ donation after his death. His story and her experiences have caused ripples not only in their family but also their community. The conversation around organ donation has continued to spread which is fantastic news and hopefully a good omen for how the law will change in England next year.
We wrapped up the morning with a discussion amongst some intensive care greats about what the gamechangers are going to be in ICM over the next few years. John Myburgh stressed a very important issue at the moment relating to the environmental impact of all the waste we get through in the ICU. Every procedure comes with a swathe of paper and plastic wrappings and waste and even much of the equipment we use is single use plastic – do we even recycle this well? Not to mention the impact 1500 delegates have had travelling across the world to this conference this week – is it time to change how we do medical conferences?
Danny McAuley thought the next thing to change the future of ICU would be increased use of point-of-care testing, for example in genetics (linking back to Alice and Hugh’s talk) to tailor treatment to the individual patients. Hannah Wunsch thinks it will be improving the way patients and their families sleep, with the aim that improved sleep would improve recovery. Everyone loves a nap. We’re all in favour.
In the cardiac arrest stream, Ben Singer talked about pre-hospital ECMO and SUB 30 which aims to get witnessed out-of-hospital cardiac arrest patients on ECMO within 30 minutes. They’ve recruited two patients so far and are trying to recruit six; this is only a feasibility trial to see if a full trial is possible so we’re a way off any results yet but one to watch in the next few years.
Yet more targeted temperature management with Niklas Nielsen giving a brief TTM2 trial update (no results yet as recruitment hasn’t finished) and guarded on his opinion of the probable outcome. Gavin Perkins talked about what ILCOR does – it’s not all guidelines and statements, but also education and global training on CPR in order to raise awareness with the public as well as clinicians.
Lastly Sara Gray talked about the nightmare we all have – what if that cardiac arrest patient who we think is brain dead and that we are withdrawing on, or considering for organ donation, wakes up, survives, and goes home with a good outcome. It’s happened before and will happen again but how can we prognosticate well? She advises a multimodal assessment using tests with low false positive rates (absent pupils, absent corneal reflexes and absence of SSEPs at 72h post something, either ROSC or rewarming, dependent on your geographical location), and to be patient in order to minimise the chance of calling it wrong.
Elsewhere, LJ Mottram described the danger of what lies beneath the vocal cords and how preparing and rigorously practising for emergency scenarios can help us to deal with them more effectively. Her tweet thread below gives her key take home messages from the talk.
I’ll admit I don’t know a great deal about those weird specialties – skin, rheum, eyes, so it was great to have a session on all three in the afternoon. Richard Groves took us through the dermatological emergencies of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) as well as a few other things, with the main take home points that early identification and multidisciplinary management is key. Most rashes in intensive care are due to drugs and so given the complete lack of any variety of drugs that we use in the ICU it should be easy to identify the culprit, right?
Fiona Carley covered problems in the EyeCU (get it?) and reinforced the multidisciplinary approach to SJS/TEN; around 70% of these patients will have eye involvement which could be sight-threatening, and early ophthalmology involvement is crucial. We also need to take great care of our patients’ eyes, as often their usual protective mechanisms are rendered inefficient (by us..).
Also running throughout Monday afternoon was the choose your own adventure organ donation session. This was an interesting concept – progression through a devastating brain injury scenario was performed live on stage by actors and healthcare professionals. We were taken through the key conversations around initial notification of death by neurological criteria, brain stem testing and the planning required for these discussions. Each aspect of these discussions was punctuated by a brief interlude from Dale Gardiner, as national lead for organ donation. Lots of wise pearls not limited to, but including the following:
Try and take a SNOD with you as early as possible in these discussions.
Utilise the sounds of silence – if you use a word like death, died, dying, try waiting for the family to break the subsequent silence. If it doesn’t feel uncomfortable, you probably haven’t waited long enough. This is a key step in ensuring they understand the gravity of the information and are able to process the finality of the information.
Think about your structuring your approach to this type of discussion as per the legendary bard, William Shakespeare:
- Prologue – what does the family know so far?
- Act 1 – retell the story, with appropriate emphasis on the key information
- Act 2 – build toward a telegraphed reveal – we think that your relative has died, or we think there is no chance of recovery, and it might be time to stop
- Interval – guide toward a break, let them digest the information
- Act 3 – conclude the story with the results of brain stem testing if appropriate and move forwards to end of life care discussions and how we can help.
There were serial votes from the audience at various timepoints to direct the actors. For instance, when the option of mentioning organ donation early was voted in, there was a live demo of this, followed by a scything narrative from Dale (#carcrash). Reiteration that this part of the discussion is probably best parked until the concept of death has been confirmed and accepted….
There were further votes and live demos of what the approach could be like. A demo of of the specialist nurse pushing hard for evidence of verbal discussion was particularly interesting (#awkward), followed by one on the legal aspects of deemed consent taking priority. Both were met with equal levels of confusion and uncertainty by the acting family. The faculty used #carcrash again, but I might have gone for #legalese in this situation. Dale popped up here to remind us that the legal change in Wales actually resulted in a reduced level of consent over the first 5 months from inception, which has widely been attributed to an inappropriate focus on the legality in initial conversations. The last demo in this section used the benefits of donation to lead the discussion – interesting and persuasive.
Last series of conversations focused on the language used – should we be talking about ‘no decision = no objections’ or ‘no decision = wished to donate’ or ‘no decision = a decision to donate’. I’ll leave you to decide which of these the acting family preferred, and which got 90% of the votes… Remember that even when an individual has opted in to the concept of organ donation, family refusal still results in no progression just under 10% of the time
Last for the afternoon, a brief foray into acute on chronic liver failure
Tony Whitehouse up first, raising a sceptical eyebrow about definitions of acute on chronic liver failure and pointing out the many definitions in existence, some of which require a crystal ball. Perhaps decompensated cirrhosis is a better terminology? We were reminded that although there is lots of available data on this group suggesting bad outcomes, most of it is observational and not perhaps reflective of current practice in UK liver centres.
All well and good, but how does this help us decide who to admit? Data from CLIF-C score can give you an objective number, but remember this does not tell you exactly who will and won’t survive, it merely gives you an idea of risk.
A perhaps wiser suggestion was to focus on differentiating AOCLF from advanced and progressive cirrhosis by considering the following:
- Timing – Long term follow up helps identify an acute decompensation from progressive disease. Tricky to manage first presentations.
- Was there a precipitating event (and a treatable cause).
- Prognostication and an escape plan – what situation will you be left in after they have recovered from this acute event – are they likely to comply with a dry period for transplantation, for instance?
- Treat and see / trial of therapy
No right answers here, but a helpful take on what to consider.
Lots more fascinating stuff throughout all sessions, but we think that’s enough text for today. Enjoy your drinks reception, your catch ups, your new friends and your hangovers and we shall see you all on the morrow.
Join us tomorrow for day 2!