- na současné intenzivní medicíně - akutne.cz...- no single organ specialties - the complex...
TRANSCRIPT
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Co mne nejvíc baví a nebaví
- na současné intenzivní medicíně
OA Dr. Stibor B.ICU, Landesklinikum Baden bei Wien, Austria
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no conflict of interest
OA Dr. Stibor B.ICU, Landesklinikum Baden bei Wien, Austria
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1. xxxxxxxx
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přehled
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současné
možnosti
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intensive care:big picture
thinking
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- no single organ specialties
- the complex interplay between all the organ systems
- considering the whole patient
- life-changing decisions must be made
critical care
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evidence- based
medicine?
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Archie Cochrane. Effectiveness and afficiency. 1972.
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the first clinical trial ever (early „ICU“ trial)
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- 1948: first trial ever
- 1972: hundreds of trials per year
- 2010: ca 37.000 trials started per year
- 2019: ca 50.000 trials started per year
massive explosion of new trials
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medicine
evidencebased
evidencebased
opinion
based
experience
based
powerbased
logicbased
erraticbased
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Does this study mean I should change my
practise…?
Does this study mean I should change my
practise…?
Are these patients the same as mine…?
Are these patients the same as mine…?
Is this study valid…?Is this study valid…?
If it is published in NEJM, it must be good, right?If it is published in NEJM, it must be good, right?
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harmonizing
clinical experience
andevidence-based medicine
harmonizing
clinical experience
andevidence-based medicine
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clinical jazz
clinical jazz
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guidelines?
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Brain Trauma Foundation:
„Guidelines for the Management of Severe Traumatic Brain Injury“
Fourth Edition
- 189 publications included as evidence to support:
- 28 recommendations covering 18 topics
- the publication reports on:
- 5 Class 1 studies
- 46 Class 2 studies
- 136 Class 3 studies
- 2 meta-analyses
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Living Guidelines
Living Guidelines
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klinickéstudie
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- trvají příliš dlouho
- mají málo pacientů
- nešťastný design
- nedojde k publikaci
- většina je no difference, některá harmful
- nejčastější závěr: potřeba dalších studií…
- při publikaci jsou už staré, pro praxi nepoužitelné
studie
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řešení?
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Adaptive Trials
Adaptive Trials
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real lifedata
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cytokine removal therapy
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Cytosorb® pre-filter, Cytosorb ® post-filter, Jafron ® post-filter
cytokine removal vs platelets?
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finance
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ICUICU
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andexanet alfa?
Eliquis (apixaban) 10 hours later
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bojs větrnými
mlýny
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každý pacient na ICU každý den předozadní snímek plic
+ snímek při příjmu
+ snímek po zavedení katetrů (CVK, CoolGuard, ECLS…)
+ snímek při náhlé změně zdravotního stavu
+ ostatní radiol. vyšetření (CT)
radiologická vyšetření
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pac. Helga A., 1958
Fournierova gangréna (+MOF)
1.12.2018 – 27.5.2019 (178 dnů)
radiologická vyšetření
C/P CT
198 x 9 x
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2000
počet alogenních transfuzí klesl
o 12%
(v tisících)
počet hospitalizací vzrostl
o 44% (!)
(hospital. na 10 tis. obyv.)
2009
645
1600
2300
567
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to save a net cost of
€100 million
nationwide every year
possible to save a net cost of
€200 million
nationwide every year
BJA,2012;109(1):55-68
Prof. Gombotz, persönlich X/2015
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shit
happens
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Eporatio 30.000 IU s.c. á 3d (17.1. – 11.5.2017)
celkem 1.170.000 IU
Ferinject 500 mg i.v. á 7d (17.1. – 18.4.2017)
celkem 7.000 mg
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with permissionwith permission
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with permissionwith permission
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snahao
dokonalost
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defensivemedicine
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defensive medicine
diagnostic test or medical treatment that is not necessarily the best option for the patient, but an option that mainly serves the function to protect the physician against the patient as potential plaintiff
ordering unnecessary CT scans, biopsies, and MRIs, and prescribing more e.g. antibiotics than medically indicated
in Switzerland, for instance, the rate of hysterectomy in the general population is 16%, whereas among female doctors and female partners of doctors it is only 10%
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polypragmazie
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ATB dosis
Bramitob 300 mg 3x
Ecalta 100 mg 1x
Fortum 2,0 g 3x
Lidaprim 250 ml 2x
Vancomycin 250 mg p.o. 4x
Doribax 3 x 2g kontin.
polypragmazie
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800
600
400
200
1160 Stk costs of Bridion®
Landesklinikum Baden bei Wien; I-XII 2012
89.122,80€
costs of Bridion®
Landesklinikum Baden bei Wien; I-XII 2012
89.122,80€
Baden
Wr. N
eustadt
Wr. N
eustadt
St. Pölte
n
St. Pölte
n
BridionBridion
>10
0 S
tk/J
ahr
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marnáléčba
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When we become
very sick, or very old,
we are programmed to die.
When we become
very sick, or very old,
we are programmed to die.
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OP OP
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ICU ICU
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vývojpoznání
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Crit Care Med. 2013;41:99-115.
33 ºC vs 36 ºC
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Crit Care Med. 2013;41:99-115.
33 ºC vs 36 ºC
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RhinoChill RhinoChill
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Circulation.2010;122:729-736.
Coclusions: Prehospital intra-arrest transnasal cooling is safe and feasible and is associated with a significant improvement in the time intervals required to cool patients.
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JAMA.2019;321(17):1677-1685.
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11.02.2012
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- seven ECMO
- warming (one degree per 10 minutes)
- six hours after the accident ROSC
- everybody awoke at the same day
- 100% survival
- good neurological outcome in six of seven
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Patientdata
monitoring system
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„ordinace"
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"teplotka"
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osobnosti
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Professor of Pulmonary MedicineDirector of the Department of Pulmonary and
Infectious Diseases at Hannover University School of Medicine, Hannover, Germany
President of the European Respiratory SocietyPast President of the German Society of
PneumologyVice President of the German Society of SepsisPast President of the German Society of Internal
Intensive Care (DGIN)executive board of the German Society of Critical
Care (DIVI)executive board member of the German Center for
lung research (DZL)internal advisory board member of the German
Center for Infectious Disease Research (DZIF)member of the review panel for clinical studies of
the German Research Foundation (DFG)chairman of the Community-acquired Pneumonia
(CAPNETZ) foundationeditorial board of the European Respiratory
Journaleditorial board Respiratory Medicineeditorial board Thoracic Cardiovascular Surgeonpublished: ca 800 papers and over 150 books.
Prof. Tobias Welte
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Tobias Welte
Director of the German Center for Lung Research
"Pathophysiology of respiration:
from basic sciences to the bedside "
2019
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selský rozumselský rozum
HausverstandHausverstand
common sensecommon sense
buo sensobuo senso
sentido comúnsentido común
здра́вый смысл здра́вый смысл
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…děkuji Vám za pozornost