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Update inIntensive Care
Australasian Perioperative Medicine Symposium
Melbourne 2018
Our background
NZ trainedAnaesthetist-Intensivist
Rockhampton for last 6 years
?Anaesthetist-Intensivist
Royal Adelaide Hospital for ?
Conflicts
Nil
Update of Perioperative Critical Care Literature
after 2017
Criteria:Related to perioperative care
Original Research, Systematic Reviews / Meta analysis
Goals
Elective Surgery
Admit Post Operatively to…….
Definitions differ and
arechanging
UK
L0 – ward
L1 – COU
L2 – HDU
L3 – ICU
CICM
L1 – HDUMV for 24hrs
L2 – ≥ 6 beds200 MV/yr
L3 – ≥ 8 bedsLong term
care
QLD/NSW/SA
L4 – HDUMV for 24hrs
L5 – MV, RRT, invasive
monitoring,≥ 4 MV beds
L6 – tertiary, subspeciality, ≥ 8 MV beds
Level 1.5 units
UK
L0 – ward
L1 – COU
L2 – HDU
L3 – ICU
CICM
L1 – HDUMV for 24hrs
L2 – ≥ 6 beds200 MV/yr
L3 – ≥ 8 bedsLong term
care
QLD/NSW/SA
L4 – HDUMV for 24hrs
L5 – MV, RRT, invasive
monitoring,≥ 4 MV beds
L6 – tertiary, subspeciality, ≥ 8 MV beds
Level 1.5 units
SNAP2:EpiCCS – Postoperative Critical Facilities in the UK
Prospective Observational Cohort Study – 1 week
n = 257 hospitals, 15,000 patients
72 hospitals (28%) have enhanced ward areas for high risk patient not admitted to ICU/HDU
109 enhanced care areas
SNAP2 results release – Evidenced Based Perioperative Medicine Conference, London, 2018
30% of patients in UK looked after on wards (evolved out of necessity)
Invasive monitoring
Inotropes/Vasopressors
NIV
By non-intensivists (surgeons)
SNAP2 results release – Evidenced Based Perioperative Medicine Conference, London, 2018
30% of patients in UK looked after on wards (evolved out of necessity)
Invasive monitoring
Inotropes/Vasopressors
NIV
By non-intensivists (surgeons)
?may do well or may not more research needed
SNAP2 results release – Evidenced Based Perioperative Medicine Conference, London, 2018
Question
Elective Admission to ICU/HDU
Carotid Endarterectomy?
Elective Admission to ICU/HDU
Thyroidectomy?
Parathyroidectomy?
Elective Admission to ICU/HDU
Gastric Bypass surgery (laprascopic)?
Uvuloplasty for OSA?
Craniotomy – excision of Meningioma?
Elective Admission to ICU/HDU
Australian and New Zealand practice
High-dependency and intensive care beds are limited
40% of all ICU admissions follow surgery
There is evidence that this resource is not allocated to patients at greatest need
Recent studies have failed to identify a survival benefit of routine ICU admission after elective surgery
Kahan BC, et al. Relationship between critical care provision and mortality following elective surgery: prospective analysis of data from 27 countries. Intensive Care Med. 2017 doi:10.1007/ s00134-016-4633-8 Gilles MA, et al. British Journal of Anaesthesia, 2017;118: 123–31
Paucity of data around who needs to be admitted to
ICU
Elective surgical admissions to ICUPlanned analysis of data collected during an international 7-day cohort
study. All adult patients undergoing elective surgery with a planned hospital
overnight stay Aims: assess the association between use of critical care resources and
in-hospital mortality after elective surgery.
44,814 patients, 474 hospitals (15,806 patients from 126 hospitals in low/middle income countries, and 29,008 patients from 348 hospitals
in high income countries)
Kahan BC, (2017) Relationship between critical care provision and mortality following elective surgery: prospective analysis of data from 27 countries. Intensive Care Med
Hospital-level analysis of mortality and ICU admission immediately after surgery44,363 patients from 469 hospitals were included in the analysis. No association between critical care admission immediately after surgery and mortalityNo evidence that this association differed between low or middle countries and high income countries
Hospital-level analysis of association between mortality and critical care capacity44,342 patients from 468 hospitals were included in the analysis. No association between critical care capacity and mortality. No evidence that this association differed between low or middle and high income countries
Elective surgical admissions to ICU
Why?
How can this be!!!!
Within individual procedures, there was wide interhospital variation in the range of early ICU admission rates (hysterectomy 0.07–14.4%, lower gastrointestinal resection 1.3–95%, endovascular aortic aneurysm 1.3–95.2%). The individual hospital accounted for a large proportion of the variation in early ICU admission rates
Elective surgical admissions to ICUWhy?
Inability to account for unknown variables or interactions in risk adjusted model
Hospitals with very good ward-based care, the incremental benefit of critical care admission would be reduced.
Critical care resources may not have been allocated to patients at greatest risk of death because of inadequate risk assessment.
Wide variation amongst hospitals in critical care utilization
Unplanned ICU/HDU
Admission
Unplanned ICU/HDU Admission
Well validated marker of quality and safety
Higher severity of illness and mortality12 vs 21% @ 30 days36 vs 45% @ 4 years
Increased organ support and longer LOS
Gilles MA, et al. British Journal of Anaesthesia, 118 (1): 123–31 (2017) Harris S, et al. Impact on mortality of prompt admission to critical care for deteriorating ward patients: an instrumental variable analysis using critical care bed strain Intensive Care Med (2018) 44:606–615
Afterhours ICU/HDU Admission
Morgan DJ, et al. British Journal of Anaesthesia, 2018;120: 1420-1428
Afterhours ICU/HDU Admission
Afterhours ICU/HDU Admission
Afterhours ICU/HDU Admission
Perioperative Geriatric Service
60% of all General Procedures are performed on >65yrs
Step-wise increase in mortality and morbidity above 50yrs
Medical complications > Surgical complications
Styan L, et al. Establishing a successful perioperative geriatric service in an Australian acute surgical unit. ANZ J Surg 88 (2018) 607–611
Perioperative Geriatric Service (Logan) Pre and Post Study
Acute Surgical Unit – Consultant Led
1.2 FTE Consultant Geriatrician
Comprehensive assessment within 24hr of admission (weekday)
Styan L, et al. Establishing a successful perioperative geriatric service in an Australian acute surgical unit. ANZ J Surg 88 (2018) 607–611
Perioperative Geriatric Service (Logan) Pre and Post Study
Service GoalsPreoperative optimisation
Facilitation of early rehabilitationDischarge planning
Supporting ceiling of careEnd of Life decision making
Styan L, et al. Establishing a successful perioperative geriatric service in an Australian acute surgical unit. ANZ J Surg 88 (2018) 607–611
Perioperative Geriatric Service (Logan) Pre and Post Study
ResultsGeriatric admissions increased 32%
Surgical interventions increased by 11%
More medical complications identified (1433%)Delirium
No change in surgical complications, in-hospital mortality, 30 day mortality or LOS
Styan L, et al. Establishing a successful perioperative geriatric service in an Australian acute surgical unit. ANZ J Surg 88 (2018) 607–611
Frailty
=
a state of increased vulnerability to stressors
Walston, J et al. (2006) - Research agenda for frailty in older adults: toward a better understanding of physiology and etiology - J Am Geriatr Soc, vol. 54, pg. 991-1001
Frailty
Systematic Review (2017) – Frailty in ICU
10 observational studies3030 patients
927 frail and 2103 fit
Mortality and Frailty
Muscedere J, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis Intensive Care Med (2017) 43:1105–1122 44:606–615
FrailtyNo difference among frail and non-frail patients in the receipt of
MV, vasoactive drugs or ICU stay
Increasing severity of frailty associated with worse outcomes
Higher hospital mortality(RR 1.7, p<0.00001)
Higher long-term mortality(RR 1.5, p<0.00001)
Frailty is amulti-system disorder
prognosis
Consider when presenting for major emergency surgery
Cardiac Surgery
Patient• 88 yo, Male. At home with wife, independent living• Progressive SOBOE, now NYHA 2• Frailty Index = 0/4• Reformed smoker (40 years), no alcohol• Hypertension, extensive PVD (with AAA), hypercholesterolemia• eGRF = 54 mls/min• ECHO: EF=55%, peak and mean gradients, 65 and 38 mmHg,
valve area=0.75 cm2/m2
• FEV1 = 2.16, FEV1/FVC = 70%
• Planned for AVR and x1 CABG
Question
Open Heart Surgery
TAVI +/- PCI
Medical Management
TAVR vs Cardiac Surgery• Previous trials: similar survival among high-risk patients with aortic stenosis, with transcatheter
aortic-valve replacement (TAVR) and surgical aortic- valve replacement.
• New: Randomized trial involving intermediate-risk patients. 2032 patients, at 57 centers. • Primary end point: death from any cause or disabling stroke at 2 years.
• Before randomization, 76.3% of the patients were included in the transfemoral-access cohort and 23.7% in the transthoracic-access cohort.
• Results: 19.3% in the TAVR group and 21.1% in the surgery group (hazard ratio in the TAVR group, 0.89; 95% confidence interval [CI], 0.73 to 1.09; P=0.25).
• In the transfemoral- access cohort, TAVR resulted in lower rate of death or disabling stroke than surgery (hazard ratio, 0.79; 95% CI, 0.62 to 1.00; P=0.05),
• TAVR: larger aortic-valve areas than did surgery and lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation
• Surgery: fewer vascular complications and less paravalvular aortic regurgitation.
Leon M, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients N Engl J Med 2016;374:1609-20
TAVR vs Cardiac Surgery - SummaryTAVR is for patients with aortic stenosis at high risk for early death and major complications from surgery, particularly if the patient can be treated by a transfemoral approach.
Surgery is associated with higher rates of acute kidney injury, atrial fibrillation, and transfusion requirements
TAVR is associated with higher rates of aortic regurgitation and need for pacemaker implantation but better aortic-valve haemodynamics
Patient
During assessment for TAVI, deemed unsuitable due to peripheral vascular anatomy
Accepted and consented for open heart surgery
Question
Patient
Post operative: low cardiac output state, in need of inotropes, escalating adrenaline, milrinone and noradrenaline…
Levosimendan??
Levosimendan
• Multicenter, randomized, placebo-controlled, phase 3 trial
• Efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery
• Patients were randomly assigned to receive either intravenous levosimendan
• (at a dose of 0.2 μg/kg/minute for 1 hour)followed by a dose of 0.1 μg/kg/minute for 23 hours) or placebo
• Infusion started before surgery.
• Multicenter, randomized, double-blind, placebo-controlled trial
• Patients in whom perioperative hemodynamic support was indicated after cardiac surgery
• Patients were randomly assigned to receive levosimendan (in a continuous infusion at a dose of 0.025 to 0.2 μg/kg/minute ) or placebo, for up to 48 hours or
• until discharge from ICU, in addition to standard care
Levosimendan
• Among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass
• Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo
• In patients who required perioperative haemodynamic support after cardiac surgery
• Low-dose levosimendan in addition to standard care did not result in lower 30-day mortality than placebo
Levosimendan
These studies suggest that despite its unique mechanism of action, levosimendan has no clear advantage over conventional inotropic drugs for the management of perioperative low cardiac output syndrome in patients undergoing cardiac surgery.
Mehta RH, et al. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery. N Engl J Med 2017;376:2032-2042
Levosimendan - meta-analysis (including above trials)
Lee CT, et al. Effects of levosimendan for perioperative cardiovascular dysfunction in patients receiving cardiac surgery: a meta-analysis with trial sequential analysis Intensive Care Med (2017) 43:1929–1930
Patient
Now resolving organ failure, extubated to CPAP with FiO2 of 0.5
Hb = 75 gm/L
Transfuse ??
If yes to transfusion, freshest blood possible??
Transfusion threshold and Cardiac Surgery• Previous studies: patients undergoing cardiac surgery at moderate-to-high risk for death, a restrictive
transfusion strategy was non inferior to a liberal strategy with respect to death, myocardial infarction, stroke, or new-onset renal failure with dialysis at 28 days
• Aims: clinical outcomes at 6 months after surgery.
• Methods: 5243 adults undergoing cardiac surgery randomly assigned to restrictive red-cell transfusion strategy (Hb <75 g/L) or liberal red-cell transfusion strategy (Hb <95 g/L) intraoperatively or postoperatively when the patient was in the ICU or was <85 g/L when in the ward.
• The primary composite outcome death, myocardial infarction, stroke, or new-onset renal failure with dialysis occurring within 6 months after the surgery.
• Secondary composite outcome included all the components of the primary outcome as well as ED visit, hospital readmission, or coronary revascularization occurring within 6 months after the index surgery.
• Results: At 6 months the primary composite outcome had occurred in 17.4% in the restrictive group and 17.1% in the liberal group (odds ratio, 1.02; 95% CI, 0.87 to 1.18; P=0.006 for noninferiority).
• Mortality was 6.2% in the restrictive-threshold group and 6.4% in the liberal-threshold group (odds ratio, 0.95; 95% CI, 0.75 to 1.21). There were no significant between-group differences in the secondary outcomes.
Mazer CD, et al. Six-Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery
Cardiac Surgery - transfusion
Transfusion and age of RBC
• Multicenter, randomized, double-blind trial, critically ill adults to receive either the freshest available, compatible, allogeneic red cells (short-term storage group) or standard-issue (oldest available), compatible, allogeneic red cells (long-term storage group).
• The primary outcome was 90-day mortality.
• Patients 18 years of age or older who were admitted• to a participating ICU, who had an anticipated• ICU stay of at least 24 hours, and in whom• the medical staff had decided to transfuse one or more red-cell units were
eligible for inclusion
Cooper D, et al. Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults N Engl J Med 2017;377:1858-67.
Transfusion and age of RBC• 2457 patients in the short-term storage group (mean storage duration of 11.8 days) and 2462 patients
in the long-term storage group (mean storage duration of 22.4 days)
• At 90 days, 24.8% died in the short-term storage group and 24.1% in the long-term storage group (absolute risk difference, 0.7 percentage points; 95% CI −1.7 to 3.1; P = 0.57).
• At 180 days, the absolute risk difference was 0.4 percentage points (95% CI, −2.1 to 3.0; P = 0.75). • Most of the prespecified secondary measures showed no significant between-group differences in
outcome.
• No significant between-group differences in rates of persistent organ dysfunction or death at day 28, new bloodstream infections, mechanical ventilation, and renal-replacement therapy; or ICU length of
• Febrile non haemolytic transfusion reactions occurred more frequently in the short term storage group
• Transfusion of the freshest available RBC as compared with standard-issue (oldest available) RBC provides no clinically meaningful benefits in critically ill patients.
Platelet storage• Systematic review to assess association between platelet storage time and
clinical or transfusion outcomes in patients receiving allogeneic platelet transfusion
• 18 studies, five included 4719 critically ill patients and 13 included 8569 haematology patients.
• The studies in critically ill patients were retrospective and did not find any association between platelet storage time (stored for up to 5 days) and mortality and sepsis
• Of the 13 studies in haematology patients, platelet storage time was not associated with bleeding, sepsis or mortality, in critically ill patients or haematology patients.
• The freshest platelet (less than 3 days) were associated with a better count increment, but not bleeding events.
Question
Patient
Now resolving organ failure, extubated to oxygen via nasal cannula
Oxygen Saturation target…..
100% 98% 96% 94% 92% 90% 88%??
Supplemental O2 administered to acutely unwell is common
Yet it may have detrimentalpulmonary and systemic effects
(absorption atelectasis, ALI, inflammatory cytokine production, CNS toxicity, reduced cardiac output, cerebral vasoconstriction, coronary vasoconstriction)
O2 administration in non-hypoxemic patients showed no clear benefit and possible harm
(myocardial infarction, stroke, traumatic brain injury, cardiac arrest and sepsis)
Improving Oxygen Therapy in Acute-illness systematic review and meta-analysis
Systematic Review of 25 RCTs
n = 25 RCTs, 16,000 critically unwell patients withSepsis, Trauma, Stroke, MI, Cardiac Arrest, Emergency Surgery
(elective surgery excluded)
Conservative vs Liberal Oxygen Strategy(median baseline SaO2 of 96% (range 94–99%, IQR 94–96%)
Chu DK, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis Lancet 2018; 391: 1693–705
Improving Oxygen Therapy in Acute-illness systematic review and meta-analysis
Liberal oxygen supplementation median FiO2 of 0.52 (range 0.28–1.00; IQR 0.39–0.85)
median baseline SaO2 of 96% (range 94–99%, IQR 94–96%)
Conservative oxygen supplementation median FiO2 0.21 (range 0.21–0.50; IQR 0.21–0.25)
median baseline SaO2 of 96% (range 93–98%; IQR 95–97)
median duration of 8 hrs (range 1–144 hrs; IQR 4–24)
Chu DK, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis Lancet 2018; 391: 1693–705
As SpO2 increases, mortality increases
Chu DK, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis Lancet 2018; 391: 1693–705
Improving Oxygen Therapy in Acute-illness systematic review and meta-analysisThe Liberal vs Conservative oxygen group had increased:
In-hospital mortality (RR 1.21, 95% CI 1.03–1.43, I2=0%, high quality)30 day mortality (RR 1.14, 95% CI 1.01–1.29, I2=0%, high quality)
12 month mortality (RR 1.10, 95% CI 1.00–1.20, I2=0%, high quality).
number needed to harm, for one death, is approximately 71 (95% CI 37–1000).
Morbidity outcomes were similar between groups. (risk of hospital-acquired pneumonia, any hospital-acquired infection, and hospital LOS)
Chu DK, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis Lancet 2018; 391: 1693–705
Improving Oxygen Therapy in Acute-illness systematic review and meta-analysis
Is there a SaO2 “sweet spot”?94-96%
Is it the FiO2?
Chu DK, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis Lancet 2018; 391: 1693–705
Question
Patient88 yo male, Day 6 post AVR and CABG x1
Day 2 post discharge from ICU
Respiratory Rate = 26 breaths/minGCS = 13 (E=3, M=6, V=4)
Temperature = 37.60 C
Is this patient septic?
Sepsis = life threatening organ dysfunction caused by a dysregulated host response to infection.
Organ dysfunction quantified by Sequential Organ Failure Assessment (SOFA).
New Sepsis Definitions (2016)
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis – 3) – Singer et al, JAMA 2016;315(8):801-810
Sepsis Quick SOFA Score (qSOFA)
2 or more:
RR ≥ 22/min
Altered mentation
SBP ≤ 100mmHg
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis – 3) – Singer et al, JAMA 2016;315(8):801-810
Hospital Mortality = 10%
Septic Shock
Vasopressor requirementpost fluid resuscitation
Lactate > 2mmol/L
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis – 3) – Singer et al, JAMA 2016;315(8):801-810
Hospital Mortality = 40%
qSOFA does not replace SIRS in the definition of sepsis – Vincent et al, Critical Care 2016 20:210
More specific
Clinically more helpful
Doesn’t require lab tests
Facilitates earlier recognition
Greater consistency with research and trials
Post-operative Sepsis
Post operative sepsis
Ou et al. ‘The impact of post-operative sepsis on mortality after hospital discharge among elective surgical patients: a population-based cohort study’ Critical Care (2017) 21:34
Post-operative sepsis• 1857 (1.3%) had post-operative sepsis.
• Sepsis vs Non-sepsis mortality at • 30 days, 4.6% vs 0.7%• 60 days, 6.7% vs 1.2%• 90 days, 8.1% vs 1.5%• 1 year were, 13.5% vs 3.8%
• After adjustment, post-operative sepsis remained independently associated with a higher mortality
• 30-day mortality HR 2.75, 95% CI 2.14–3.53; • 60-day mortality HR 2.45, 95% CI 1.94–3.10; • 90-day mortality HR 2.31, 95% CI 1.85–2.87; • 1-year mortality HR 1.71, 95% CI 1.46–2.00).
• This risk is particularly high in the first month, in older age patients and in the presence of severe/very severe co-morbidities
Ou et al. The impact of post-operative sepsis on mortality after hospital discharge among elective surgical patients: a population-based cohort study Critical Care (2017) 21:34
Post operative sepsis
Incidence low (1.3%)
Large mortality effect
Elderly = more vulnerable
Question
Patient
88 yo male, Day 6 post AVR and CABG x1
Respiratory Rate = 26 breaths/minGCS = 13 (E=3, M=6, V=4)
Temperature = 37.60 C
PaO2/FiO2 = 150mmHgA CXR is taken….
Does this patient have
ARDS?
ARDS
Definitions have changed
Old Definition
Acute Onset
PaO2/FiO2 ratio < 300mmHg
Bilateral infiltrates
No evidence of LA hypertension
ALI
Fa E, et al. Acute Respiratory Distress Syndrome Advances in Diagnosis and Treatment JAMA. 2018;319(7):698-710
Fa E, et al. Acute Respiratory Distress Syndrome Advances in Diagnosis and Treatment JAMA. 2018;319(7):698-710
Deep SedationProne
ParalysisRecruitment
ECMOHFOV
?NO?Prostacycline
Fa E, et al. Acute Respiratory Distress Syndrome Advances in Diagnosis and Treatment JAMA. 2018;319(7):698-710
Deep SedationProne
ParalysisRecruitment
ECMOHFOV
?NO?Prostacycline
Question
Anaesthetists,What mode of ventilation
due you use?
Volume or PressureControl?
Question
When you are reallyworried about some
one’s lungs what mode do you use?
VCV or PCV
Mechanical Ventilation
Post-operative pulmonary complications
PEEPVentilatory driving pressure (Pplat – PEEP)
Oxygen partial pressure
Bagchi A, et al. The association of postoperative pulmonary complications in 109,360 patients with pressure-controlled or volume-controlled ventilation. Anaesthesia 2017, 72, 1334–1343
Mechanical Ventilation
Is Volume Control better than Pressure Control?
Single center, observational study
2007-2015
Extubated at the end of the case
PCV 18,000 matched with VC 18,000 from 91,000
Bagchi A, et al. The association of postoperative pulmonary complications in 109,360 patients with pressure-controlled or volume-controlled ventilation. Anaesthesia 2017, 72, 1334–1343
Mechanical VentilationAverage duration = 155 minutes
Many operationsNeuroOMFOrthoENT
PlasticsThoracic
TransplantUrologyVascular
Surgical OncologyPaediatrics
Mechanical Ventilation
Pressure Control associated with:
Higher post-operative pulmonary complications
Due to:
? Variable TV and higher Driving Pressure? Low or no PEEP
Intraoperative PCVincreased pulmonary
complications
Use > 5cmH20 PEEP
Nutrition
“To eat is a necessity, but to eat intelligently is an art”
François de La RochefoucaldRoman cardinal who died at age 86 (1558-1645)
NutritionGoal = Maintaining Protein Balance up to about 1.8g/kg/day
Prevention of rapid loss of muscle mass = lowers mortality
Body composition, especially LBM, is associated with better clinical outcomes
No harm in hypocaloric feeding if protein requirements are met
Nutrition
Probiotics infectious complications
But, not mortality
May help with early return of gut function
Nutrition (Early)ENTERAL - high calories/overfeeding harmful
PARENTERAL - TPN within 7 days of ICU admission not required
Enteral remains preferable over parenteral nutrition, although no inferiority of parenteral with respect to mortality and infections is reported in recent studies
(Immuno) Nutrition
High amino acids – Glutamine – Selenium – Fish Oil –
Vitamin C + Thiamine + Corticosteroids – +/-
Mobilisation
“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have the
safest way to health”
HippocratesGreek physician, the "Father of Medicine” c. 460 – c. 370 BC
Mobilisation
Physical inactivity and muscle disuse muscle atrophyCritical illness escalates that process
Effective if starts early (within 72 hours)
Implementing early mobilization is challenging, requires cultural change and inter-professional engagement
MobilisationCurrent evidence suggests early mobilization is safe and feasible and
may improve functional recovery
Improved functional abilities at hospital discharge and reduced ICU and hospital length of stay
Lack of data on long-term outcomes such as mortality, health-related activities of daily life or rate of return to work
Lack of evidence of benefit in neurocritical care
Early, frequent, and multimodal physical therapies in combination with early, enteral (if possible),
hypocaloric, and high-protein provision are effective strategies to maintain skeletal muscle mass during
critical care.
Delirium
Acute, fluctuating disorder of attention and awareness
Incidence:Major elective surgery – 15-25%# NOF and Cardiac Surgery – 50%
ICU – 75%End of Life – 85%
Hyperactive (25%) vs Hypoactive (75%)
Hypoactive has worse prognosis
Can persist well beyond hospital discharge (weeks)
Predisposing factors
• Older age• Dementia • Functional disabilities, • High burden of coexisting
conditions • Male gender• Poor vision and hearing• Depressive symptoms• Mild cognitive impairment• Laboratory abnormalities• Alcohol abuse
Precipitating factors
• Drugs (especially sedative hypnotic agents and anticholinergic agents),
• Surgery• Anaesthesia• High pain levels• Anemia• Infections• Acute illness, and acute
exacerbation of chronic illness
Preventing Delirium in the Intensive Care Unit – Brummel, N. E et al (2013) Crit Care Clin 29: 51-65Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit – Alvarez, J Crit Care 2016;37:85-90
ABCDE of Delirium
Management in ICU
Delirium
But there is
a F…
Family
Pharmacology in DeliriumDrugs to prevent delirium is proving difficult
Use light sedation and avoid benzodiazepines
Use either propofol or dexmedetomidine
Anti-psychotic agents should be reserved for unremitting symptoms that threaten patient/staff safety
(Haloperidol, Olanzapine, Quetiapine)
DexmedetomidineAlpha 2 agonist – anxiolysis, sedation and analgesia
May decreases post-op Delirium(intra, post and/or peri opertaive use
Cardiac and non-cardiac)
Meta-analysis
Uncertain for reduction in mortality, delirium duration, length of ICU and hospital stay, duration of of MV, time to extubation
Duan X, et al. Efficacy of perioperative dexmedetomidine on postoperative delirium: systematic review and meta- analysis with trial sequential analysis of randomised controlled trials. British Journal of Anaesthesia, 121 (2): 384e397 (2018)
Intravenous Fluids
Restrictive vs
LiberalFluids
n = 3,000Urgent/Time critical surgery excluded
Liberal fluidvs
Restrictive fluid
No change in disability free survival at 1 year AKI + RRT
Surgical site infection
Liberal Fluids
• 3L intraoperatively
• 125mL/hr
• Hartmans
n = 3,000Urgent/Time critical surgery excluded
Liberal fluidvs
Restrictive fluid
No change in disability free survival at 1 year AKI + RRT
Surgical site infection
Salinevs
Balanced Salt Solution
Semmler M, et al. Balanced Crystalloids versus Saline in Critically Ill Adults N Engl J Med 2018;378:829-39
Single center RCT – cluster, cross-overn = 15,802
Salinevs
Balanced Solution (HMN or P148)
Composite Primary = Death, New RRT, orPersistent renal dysfunction (Cr > 200% baseline) @ 30 days
Semmler M, et al. Balanced Crystalloids versus Saline in Critically Ill Adults N Engl J Med 2018;378:829-39
NS 7860 vs Balanced 7942
Major kidney composite eventNS 14.3% and Balanced 15.4%
(OR 0.9, 95% CI 0.82 to 0.99, p = 0.04)
No difference individually:In-hospital mortality
New RRTPersistent renal dysfunction
Conclusion = Balance Solution in ICU leads to a decrease in composite kidney outcomes.
Balanced Crystalloids and 0.9% Saline
Take home messages
(1)
Critical Care Admission- More Q’s than A’s
(2)
Frailty – MSD with major impact on ICU
outcome
(3)
Blood Transfusion –less is more
“Age is not a barrier”
(4)
O2 in critical care –less is more
(5)
Sepsis –qSOFA and prevent
post-op sepsis
(6)
Volume Control + PEEP
(7)
Nutrition – not too much, give protein
(8)
Mobilise and identify delirium
(9)
Fluids – Be less restrictive
(10)
Fluids – balanced salt solution in ICU,
maybe
Questions
Question
If a patient is booked for an post op HDU bed, what do you do when
there isn’t one?
Uncomplicated Elective Surgical Patients.
Who need not be admitted to ICU/HDU?
(1) Cancel(2) Risk Assess(3) Extended stay PACU(4) Ward with special(5) Ward(6) Close observation unit
Question
Who follows these patients up?
(1) Anaesthesia(2) ICU(3) Medicine(4) Geriatrics(5) Surgery
Novel Idea!
Send them to ward and book an ICU bed for POD 3?
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