ommunications ritical are C C C A monthly newsletter of Indian Society of Critical Care Medicine The Volume 4.6 • November-December, 2009 In this issue • CRITICARE 2010 Swine Flu ................................... 1 • CRITICARE 2010 Scientific Programme Day 1 ....................................... 2, 5 Day 2 ....................................... 5, 6 Day 3 ........................................... 7 Workshops .............................. 8, 9 Registration Tariff .................... 10 • Message from the Editor .......................................... 3 • Message from the President..................................... 4 • Nagpur report ........................... 11 • Management of severe swine flu cases in ICU ....................................... 12-14 • Journal Scan ........................ 15-16 For Detail CME & Main Conference Programme (See page no 2,5-10)
Transcript
1The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
Day 2 ....................................... 5, 6
Day 3 ...........................................7
Workshops ..............................8, 9
Registration Tariff .................... 10
• Message from the Editor ..........................................3
• Message from the President .....................................4
• Nagpur report ........................... 11
• Management of severe swine flu cases in ICU ....................................... 12-14
• Journal Scan ........................ 15-16
For Detail CME & Main Conference Programme
(See page no 2,5-10)
10– 14 Feb, 2010Hyderabad
www.criticare2010.org
2
SCIENTIFIC PROGRAMME
CONFERENCE DAY-1 • Friday, 12th February, 2010 • Hall A
CONFERENCE DAY-1 • Friday, 12th February, 2010 • Hall B
CONFERENCE DAY-1 • Friday, 12th February, 2010 • Hall C
CONFERENCE DAY-1 • Friday, 12th February, 2010 • Hall D
CONFERENCE DAY-1 • Friday, 12th February, 2010 • Hall E
09:00-09:10 Org Secretary Address09:10-09:40 KEyNOTE AddRESS - Critical Care Medicine - Current and future challenges J L Vincent09:40-10:10 ThEMATIC ORATION
Safe practices save lives Manimala Rao10:10-10:35 PlENARy SESSION Shirish Prayag10:40-11:25 ISCCM ORATION ANd lIFE TIME AChIEvEMENT AwARd11:30-13:00 ThEMATIC SyMPOSIuM TRANSPlANT MEdICINE
• Liver - Julia Wendon• BMT Heart - Yatin Mehta• Infections - Om Shrivastav
14:00-15:30 PlENARy SESSIONS• PEEP in ARDS - Ram Rajagopalan• Steroids in Sepsis - Didier Payen• Fluid responsiveness - A Perel
15:30-16:00 hOT TOPIC SESSIONPandemic Preparedness - C Gomersall
16:00-16:30 PRO CON DEBATE EGDT is essential yES - J L VincentNo - Max Jonas
16:45-17:45 FREE PAPER SESSION17:45 Onwards PRESIdENT’S EvENING
14:00-15:30 PlENARy SESSIONS• Tissue Drug levels - J Lipman• CCM Training - J V Divatia• INICC data - Rosenthal
15:30-16:00 hOT TOPIC SESSION ThERAPEuTIC hyPOThERMIA - M Saxena16:00-16:30 YEAR IN REVIEW RRT in ICU - Roop Kishen16:45-17:45 FREE PAPER SESSION
11:30-13:00 ThEMATIC SyMPOSIuM EPIdEMIOlOGy & STATISTICS• RCTs - J L Vincent• Meta Analysis - JV Peter• Sub group analysis - V Nayyar• Interim analysis - R Hegde
15:30-16:00 hOT TOPIC SESSION SuRvIvING SEPSIS GuIdElINES - J L Vincent16:00-16:30 YEAR IN REVIEW HFOV Update - Praveen Khilnani16:45-17:45 FREE PAPER SESSION
11:30-13:00 ThEMATIC SyMPOSIuM ObSTETRIC CRITICAl CARE • Heart Failure - Anjan Trikha • Obstetric H’ge - S Verghese • Renal Failure - Shamik Shah • Eclampsia
15:30-16:00 hOT TOPIC SESSION bTF vS ARdS NET GuIdElINES - P Kalra16:00-16:30 yEAR IN REvIEw FluId ThERAPy 16:45-17:45 FREE PAPER SESSION
11:30-13:00 ThEMATIC SyMPOSIuM ENdOCRINE ISSuES • Insulin vs Control - R Rajagopalan • Steroid responders and non responders - Omender Singh • Vasopressin - R Chawla • Thyroid suppl - Khusrau Bajan
15:30-16:00 hOT TOPIC SESSION QuAlITy MEASuRES - Kathy Rowan16:00-16:30 CRITICARE QuIZ PART 1 - MCQ PATTERN16:45-17:45 EXECuTIvE COMMITTEE MEETING
3The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
Published By : InDIAn SoCIETy oF CRITICAl CARE MEDICInE, Bldg. No.3, No.12, 5th Floor, Navjivan Commercial Premises Co-op. Society Ltd., Dr. D. Bhadkamkar Road, Mumbai Central, Mumbai 400 008. • Tel.: (022) 6526 8504 • Telefax: (022) 2305 4843
Message from the Editor
dr. rajesh chawlaPresident Elect
Swine Flu has swept the country by storm with a high mortality which is mainly due to refrac-
tory hypoxemia and multiorgan failure.
As any patient who has fever, cough sore throat and breathlessness can be suspected to have
H1N1 infection; such patients are often referred from one centre to another due to lack of H1N1
isolation ward at every centre. For medical and legal purposes a patient with these symptoms must
be H1N1 negative before being admitted in a general MICU.
I have been managing severely ill patients with H1N1 infection and would like to share my personal
experience with you. I have never encountered such an unresponsive, severe hypoxemia which
makes you feel extremely helpless. At the same time we are also seeing patients who are H1N1
negative but present with a similar course of illness. I have never before seen these many patients
with viral infection with severe respiratory failure being admitted in our ICU in the last 20 years
of my practice. On many occasions the respiratory failure in these patients progresses very quickly
and patients have to be intubated and ventilated within 24 hours of onset. These patients are very
difficult to ventilate. Barotrauma is very common, as is pneumomediastinum, which is very common
in both ventilated and non ventilated patients. I have now realized that a plateau pressure of 30 is
high for these patients and I now try to keep it as low as possible, tolerating severe hypercapnia in
order to avoid barotrauma. I maintain an SPO2 of around 88 to 92%. Many of these patients will
come to you in outpatient and you will be surprised to see an SPO2 of around 80% in a patient who
is sitting in front of you and has mild to moderate dyspnoea . Such patients tolerate hypoxemia
very well.
In addition to the antiviral and other supportive treatment, these patients do very well if you can
maintain a respiratory rate of around 35 by applying noninvasive ventilation through the invasive
ICU ventilator. The portable pressure ventilator will not work as these patients require very high
Fio2 to maintain saturation. We also give the patients good nutrition orally while on nasal cannula
or through a nasogastric tube while on NIV and maintain an SPO2 of around 90%. This strategy has
helped us in avoiding intubation in 80% of these patients presenting with severe respiratory failure
at Indraprastha Apollo Hospitals.
I would however not recommend the use of NIV in these patients unless you have been applying
NIV for many years and have staff trained in using NIV through invasive ventilator as it is extremely
labor intensive. In addition to early invasive ventilation, HFO and ECMO are the other modalities
which are being used in these patients of severe hypoxemia all over the world. In this issue you can
go through the international guidelines for severe H1N1 infection.
The journal scan section gives the salient features of important articles published in the last few
months. Dr. Anand Kumar in an article in Chest has once again demonstrated that inappropriate
antimicrobial therapy results in a fivefold reduction of survival in patients with septic shock and
inappropriateness occurs in 20% of these patients.
The countdown for Criticare 2010 has begun. This year we expect a very large number of del-
egates. Most of the workshops are already booked and the organizing committee has put in lot of
effort to make it a grand event. Be there.
I once again request you to send to us your inputs and articles to make this bulletin a more interac-
tive and informative organ of the society.
Managing severe swine flu in ICU – A real challenge
4
Dear Friends
Best Wishes for New Year!
Criticare 2010, the Annual Conference of the ISCCM, being held from February 10-14 at Hyderabad, is now moving full steam ahead, despite the recent political happenings. The Confer-ence Organising Committee has made extensive preparations and put in an immense amount of hard work and effort to stage perhaps the biggest of the conferences held so far. The Hyderabad International Convention Centre is a fabulous venue, you will get a truly international experience here. The Scientific programme features state-of-the-art, cutting edge science along with practical, down-to-earth clinical management. The are several workshops being held simultaneously, including the Fundamentals of Disaster Management (FDM) Course, where expert faculty will pass on their knowledge and skills to small groups of delegates. This is an event that you should not miss. Please register early and in large numbers to derive the maximum advantage from this scientific feast.
The ISCCM now formally announces the launch a scheme to certify competency in critical care for members who have clinical experience in critical care but have had not had the opportunity to undertake formal training. This will be open from January 2010, and will be for a limited period of 5 years only. In this time, eligible members must complete some requirements including attending workshops and CME programmes. They must then clear an exit examination after which they will be ceritified by the ISCCM. The basic details of the scheme are as follows:
Candidates with a post graduate degree in Internal Medicine, Anaesthesiology, Chest Medicine, or General Surgery who have not previously completed IDCCM may apply for IFCCM if they meet all the following criteria:
• Life Member of Indian Society of Critical Care Medicine for at least 8 years
• At least 10 (ten) years of Critical Care experience (at least 50% of their clinical time should be in Critical Care Medicine)
• Currently practicing Critical Care Medicine at a Consultant or Associate level
• Have no conflict of interest with ISCCM
In addition it is imperative that they attend the following courses within two year period prior to appearing for the exam
• Mandatory Courses
o FCCS or BASIC Provider Course
o ACLS Course
o CME/Refresher Course (Chennai or Pune Refresher Course, Delhi Critical Care Sympo-sium or two day CME prior to National Conference)
• Any THREE of the following courses/workshops conducted by ISCCM branches or endorsed by ISCCM.
o Mechanical Ventilation, Hemodynamic Monitoring, Airway Management , ICU Procedures, Simulation Workshop, Ultrasound in ICU , Echocardiography in ICU, CRRT workshop, Toxi-cology, Neurocritical Care, Cardiac Critical Care
Candidates will have to register and start accruing credits based on attendance of above courses. A one time fee of Rs.15, 000 (Fifteen thousand only) would be charged to cover registration and exam fee. The first exam will be conducted in 2012 and this pathway will be offered only for a fixed period (until 2015). The ISCCM Executive Zonal members will take the responsibility of organizing CMEs / workshops in their areas to make it convenient for their members to meet these training requirements. The Education subcommittee with the Course Co-ordinator Dr. N. Ramakrishnan will administer this process.
This scheme is being introduced in response to requests from a large number of members. I urge members to take advantage of this scheme.
The Indian Journal of Critical Care Medicine is now indexed in Pubmed. Please send in your re-search articles relevant to critical care. This will strengthen the Journal, the ISCCM and your own scientific credentials.
Preparations for the INDICAPS Study are now complete. However the protocol has been delayed due to some technical glitches, and it will be put up shortly. Expect an SMS and email when that happens. A date for data collection will be announced soon after.
That’s all for now.
With warm regards
Dr. JV DivatiaPresident, ISCCM
Message from the President
dr. J.V. divatiaProfessor & In-Charge, Critical Care Service,
Tata Memorial Hospital Mumbai
5The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
08:00-08:30 MEET ThE EXPERT - C Rodrigues08:30-09:00 PlENARy INTENSIvISTS ANd SAFETy - Mitchell Levy09:00-09:30 Is Hypoxia Dangerous - F Kapadia09:30-11:00 ThEMATIC SyMPSOIuM SuRGICAl INTENSIvE CARE
• Burns - Suveer Singh • Polytrauma - J Chacko • Post op Cardiac patient - Y Mehta • Damage control - Bala Venkat
11:00-11:30 HANSRAJ NAYYAR SESSION11:30-12:00 PRO-CON dEbATE PROTOCOl dRIvEN wEANING wORKS
• YES - N Ramakrishnan • No - G C Khilnani
12:00-12:30 PRO - CON dEbATE ICP MONITORING IMPROvES OuTCOME • YES - Julia Wendon • NO - Uma Maheshwara Rao
12:30-13:00 PRO-CON dEbATE AdRENAlINE = NORAdRENAlINE • YES - J V Peter • NO - Roop Kishen
14:00-15:30 COMMON ICu PROblEMS • Acute Severe Asthma - J C Suri • Pancreatitis - Prachee Sathe • Status Epilepticus - S Todi • Neuromuscular weakness - S Chatterjee
15:30-16:15 PANEl dISCuSSION SAFETy - ClOSEd ICu - Prayag, Todi, A K Mani, K Rachakonda
• Pharmacokinetics - J Lipman• Drug resistance - C Rodrigues• Fever in ICU - S Chatterjee • Carbapenems & beyond - P Shastri
11:30-12:00 yEAR IN REvIEw Is DVT prophylaxis safer now? Judi Jacobi
12:00-12:30 CASE SCENARIO Difficult Ventilation Sheila Myatara
12:30-13:00 hOT TOPIC SESSION Fungal sepsis - new options Suresh Ramasubban
CONFERENCE DAY-1 • Friday, 12th February, 2010 • Hall F
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall A
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall B
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall C
6
SCIENTIFIC PROGRAMME
14:00-15:30 ThEMATIC SyMPOSIuM MEChANICAl vENTIlATION • Asthma - Deepak Govil • Recruitment safety - R Rajagopalan • Airway access safety - Y K Batra • Newer modalities - Ullas G K
15:30-16:15 PANEl dISCuSSION GRAM POSITIvE INFECTIONS Gafur, Soman, R C Rodrigues
08:00-08:30 MEET ThE EXPERT - Chua09:30-11:00 ThEMATIC SyMPOSIuM TRANSFuSION PRACTICES
• Triggers - Surekha Devi• Monitoring - J Wendon • Immunology - H R Hemanth • FFP - Santosh Verghese
11:30-12:00 yEAR IN REvIEw Resuscitation - One size fits all? Azriel Perel
12:00-12:30 CASE SCENARIO Chest Trauma TVSP Murthy
12:30-13:00 hOT TOPIC SESSION NICE Registry NOvO NORdISK
14:00-15:30 ThEMATIC SyMPOSIuM POST CARdIAC ARREST • Reducing in hosp arrest - B Abraham • Hypothermia - Shiva Iyer • CPR for Pulseless pt - Ravi Marthi • CPR with Pacemaker - C Narasimhan
15:30-16:15 PANEl dISCuSSION REFuSING AdMISSION S Jog, Kalpalatha G, M Saxena
08:00-08:30 MEET ThE EXPERT - Victor Rosenthal09:30-11:00 ThEMATIC SyMPOSIuM
• Organ Donation • Endocrine Support - P Amin• Determination of Death - M Joseph • Consent in India - Lalitha Raghuram• End of Life Issues in India - R K Mani
11:30-12:00 yEAR IN REvIEw ARdS Kalpalatha Guntupalli
12:00-12:30 CASE SCENARIO - Sanjay Saproo12:30-13:00 hOT TOPIC SESSION
Colonisation vs Infection Rajeev Soman14:00-15:30 ThEMATIC SyMPOSIuM
bIOMARKERS IN ICu • AKI - J Cerda• Sepsis - R K Mani • Lung Injury M K Singh • LV Dysfunction - Amit Verma
15:30-16:15 PANEl dISCuSSION bREAKING bAd NEwS Maitree, Simran Singh, Mohan
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall C (Contd.)
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall D
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall E
CONFERENCE DAY-2 • Saturday, 13th February, 2010 • Hall F
7The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
SCIENTIFIC PROGRAMME
08:00-09:00 SyMbIOSIS SyMPOSIuMN Rao, R Chawla, B K Rao, C Nayyar
09:00-11:00 CONSENSuS SyMPOSIuM hEMOdyNAMIC ASSESSMENT • Preload assessment - Gerald Chua• RV function assessment - R Gupta• Diastolic dysfunction - R Pandit• Markers of optimization - D Payen
11:15-11:45 PRO CON dEbATE dECIdING ON RRT• Intensivist - Jose Chacko• Nephrologist - Shamik Shah
11:45-12:15 PRO CON dEbATE FOR TRAINEES Full TIME INTENSIvE CARE AS CAREER• Worthwhile - Raymond• Worthless - D Juneja
12:15-13:00 PRO CON dEbATE SCvO2 GuIdES ThERAPy• YES - Rajesh Chawla• NO - Farhad Kapadia
09:00-11:00 CONSENSuS SyMPOSIuM NuTRITION • Timing of feeding - P Amin• Post pyloric feed - • Complications of PN - S Prayag• Glutamine - K Henkeln
11:15-11:45 uPdATE SESSION Newer Technologies in ICU - Yugan Mudaliar
11:45-12:15 CASE SCENARIO Fever and low platelets - Animesh Gupta
12:15-13:00 hOT TOPIC SESSION Obesity and ICU patient - Vijay Vohra
09:00-11:00 ThEMATIC SyMPSOSIuM TOXICOlOGy Ten common mistakes - Omender SinghSmall bowel irrigation ASV - When and How much - V Tambe Oximes in OP Poisoning - JV Peter
1:15-11:45 uPdATE SESSION Newer Scoring Systems - Outcome- Kathy Rowan
11:45-12:15 CASE SCENARIO Young unresponsive patient Pradip Bhattacharya
12:15-13:00 hOT TOPIC SESSION Timing of tracheostomy - TRACMAN Roop Kishen, Ambesh
09:00-11:00 ThEMATIC SyMPOSIuM lIvER RElATEd ISSuES Hepato Renal Syndrome - Intractable ascites J WendonHepatic Failure in India - Reducing portal pressure D Kapoor
11:15-11:45 uPdATE SESSION Immunological effect of Sedatives Kamran Ghori
11:45-12:15 CASE SCENARIO HIV patient with fever and seizures Yatindra Dubey
12:15-13:00 hOT TOPIC SESSION - h1N1 PANdEMIC - vARIEd EXPERIENCES Yugan M, Subhakar, S Pooboni, Siddharth Shah
09:00-11:00 ThEMATIC SyMPOSIuM FuTuRE OF ANTIMICRObIAl ThERAPy Newer antibiotics - Paurus IraniFuture of antifungals - Future of diagnosis GafurDrug resistance - Mradul Daga
11:15-13:15 ANTIMICRObIAl STEwARdShIP PROGRAMME
CONFERENCE DAY-3 • Sunday, 14th February, 2010 • Hall A
CONFERENCE DAY-3 • Sunday, 14th February, 2010 • Hall B
CONFERENCE DAY-3 • Sunday, 14th February, 2010 • Hall C
CONFERENCE DAY-3 • Sunday, 14th February, 2010 • Hall D
CONFERENCE DAY-3 • Sunday, 14th February, 2010 • Hall E
8
SCIENTIFIC PROGRAMME
CODE WORKSHOP TOPICSA bRONChOSCOPy IN CRITICAl CAREb CRITICAl CARE NEuRO MONITORINGC hEMOdyNAMIC MONITORINGd SIM MAN bASEd SCENARIOS INCludING TRAuMAE MEChANICAl vENTIlATION - bASICS ANd AdvANCEdF blS & AClSG EXTRA CORPOREAl blOOd PuRIFICATIONh IMAGING IN CCM - bASICS ANd AdvANCEdI FCCS - INSTRuCTOR / PROvIdER COuRSEJ bASIC PEdIATRIC CRITICAl CARE wORKShOPK CRTT - CONTINuEd RESPIRATORy ThERAPISTS TRAINING l ulTRASOuNd CERTIFICATION COuRSE wINFOCuSM bASIC COuRSE IN CCMN FuNdAMENTAlS OF dISASTER MANAGEMENTO FluId ANd hEMOdyNAMIC MANAGEMENT IN PEdIATRIC INTENSIvE COuRSE
PEDIATRIC CRITICAL CARE WORKSHOPSBasic Pediatric Intensive Care Course
Fluid and Hemodynamic Management in Pediatric Intensive Care
Adaptation of Surviving Sepsis Guidelines for IndiaPediatric Emergency Transport - Need of Hour !Pediatric Shock - Choosing The Right InotropeSINGlE ThEME SyMPOSIuM
THEME: PEDIATRIC SEPSISPrevention of Nosocomial Infection & VAP in PICUManagement of Severe Malaria & Dengue Hemorrhagic ShockEmerging Infections.. H1N1, Hantavirus - What Next?HIV & Tuberculosis Management In Critically Ill Children
HOT TOPIC SESSIONRole of Steroids in the PICU
STATE - OF - THE - ARTIV Immunoglobulins - Role in the PICU
THEME: ARDS Current Concepts in Management of ARDS Panel Discussion: How to Improve Outcome of ARDS in Children - In an Indian Setting
FREE PAPERS
MEET THE EXPERTAdvanced Monitoring in the PICU (ScVO2, Intra Abdominal Pressure monitoring, CNS Monitoring, Ultrasound---etc)
SINGLE THEME SYMPOSIUMTHEME: PEDIATRIC VENTILATION - Is it Different?Lung Protective Ventilation StrategiesNon Invasive VentilationRole of Bronchoscopy in PICUHFOV and INO
MANAGEMENT GUIDELINESManagement of Severe AsthmaManagement of Status Epilepticus
CASE SCENARIOSFluid & Electrolytes in the PICU
HOT TOPICSBurns in ChildrenPediatric Endocrine EmergenciesAnalgesia in PICU - Are We Doing Enough?Feeding The Critically Ill Child
PEDIATRIC EMERGENCIESHead Injury in ChildrenEnvenomisation SyndromesToxidromes
PANEL DISCUSSIONGUIDELINES FOR SETTING UP A PICU IN INDIAOPEN HOUSE DISCUSSION FOR COMMON PICU ISSUES
WORKSHOPS 10th-11th February, 2010
WORKSHOP DAY-1 • Friday, 12th February, 2010
WORKSHOP DAY-2 • Saturday, 13th February, 2010
9The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
Basic Pediatric Critical Care Workshop (Rainbow Hospitals)Fluid and Hemodynamic Management in Pediatric Intensive Care (Lotus Children’s Hospital)
TWO DAY PRE CONFERENCE CME COURSE
Examination of critically ill patientBedside assessment of Ventricular FunctionTherapy of acute heart failureACS - controversies in managementVentilatory Waveforms - Role in bedside monitoringALI - ARDS treatment strategiesCOPD - Critical Care IssuesAbdominal compartment syndromeAcute hepatic failureIschemic Gut in Intensive CareIntensive Care Management of the Ischemic BrainTraumatic brain injury - Critical Care IssuesICU acquired Neuro Muscular WeaknessLimb compartment syndrome - Critical Care IssuesMonitoring coagulationManagement of refractory bleedingHigh Risk Surgical patientHemato - oncological malignancies in ICUPulmonary thromboembolism - Management Guidelines
How I read a scientific paperBiomarkers - clinical utilityUnderstanding Drug Pharmacokinetics in critically illPrevention of AKI in Critically ill patientsRRT - when, how and how muchEndocrine Dysfunction in Critical illnessAntibiotic Therapy - Role of AntibiogramStarting and stopping antibiotics25 years of VAPObstetric critical careManagement of Multi Drug Resistant OrganismsCritical Care of the Severely Burnt PatientEpidemic infections - Role of the IntensivistO.P Poisoning - Recent trends in the managementCommunication in ICU Health technology assessment - Effect on patient outcomeImaging the chest of an ICU patient - Role of USG and CTIssues in the management of an Organ Donor - Recent Changes in GuidelinesBariatric patient in ICU
SECRETARIAT
CRITICARE 20106-3-248/1, Indralok Complex, 304, A Block 3rd Floor, Road No. 1, Banjara hills, Hyderabad – 500034 (India)
PRE CONFERENCE CME DAY-1 • Wednesday, 10th February, 2010
PRE CONFERENCE CME DAY-2 • Thursday, 11th February, 2010
SCIENTIFIC PROGRAMME
10
11The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
The new office of Nagpur branch was inaugurated by Dr. Rajesh Chawla, President (elect) in a simple Ceremony held on 25th
October 2009. The new executive was also installed on the same day at the centre point hotel. Dr. Rajesh Chawla was the chief
guest. Prof. Dr. B. J. Subhedar was the guest of honour. Dr. Devayani Buche took over as chairman along with her team, Dr. Girish
Deshpande as Hon. Secretory, and Dr. Shubhangi Muley as Treasurer. Nine executive members were elected and were present in the
function.
The ceremony was followed by CME on Non invasive ventilation and glycemic goals in ICU, an over veiw. Dr. V. E. Tambe and Dr. Nirmal
Jaiswal were the chairpersons for the CME. Earlier Dr. S. K. Deshpande (immed. past chairman) detailed various activities of his teneure.
Dr. Anand Dongre (immed. past hon. secretary) presented secretary report. Dr. B. J. Subhedar spoke about his era of CCU & blessed
all to bring recent knowledge of critical care to Nagpur. Dr. Girish Deshpande gave the vote of thanks.
INSTALLATION CEREMONY OF ISCCM NAGPUR BRANCH
New office of Nagpur branch inaugurated
N A G P U RDr.Girish Deshpande
Hon. Secretary ISCCM (Nagpur Branch)
12
Management of severe swine flu cases in ICU
In early April 2009, a sharp increase in reports of patients requiring hospitalization for pneumonia and an unusual series of deaths were reported to the Mexican Ministry of Health. In the affected patients, a
novel swine-origin influenza A (H1N1) virus (S-OIV) was isolated. In the same month, the World Health Organization (WHO) classified the global spread of this virus as a public health event of international concern. In 9 weeks all WHO regions reported cases of pandemic (H1N1) 2009.
In this practice note, we have reviewed the management of severe swine flu cases in ICU The recommendations are primarily based on review of the literature up till 25th December, 2009.
As of October 2009, 195 countries have reported confirmed human cases of pandemic (H1N1) 2009. While the majority of illnesses caused by pandemic (H1N1) 2009 virus infection have been self-limited mild-to-moderate uncomplicated disease, severe complications including rapidly progressive pneumonia and fatal outcomes have occurred.
The pandemic (H1N1) 2009 influenza virus differs in its pathogenicity from seasonal influenza in two key aspects. First, as the majority of human population has little or no pre-existing immunity to the virus, the impact of the infection has been in a wider age range, in particular among children and young adults. Secondly, the virus can infect the lower respiratory tract and cause rapidly progressive pneumonia especially in children and young to middle-aged adults.
According to WHO estimates; approximately 10-30% of hospitalized patients require admission to intensive care units (ICU).
At-Risk Groups:
The following groups of patients are at risk of developing influenza complication when infected:
• Infants and children aged less than 5
• Elderly (>65 years)
• Nursing home residents
• Pregnant women
• Patients with chronic co-morbid conditions such as chronic cardiovascular, respiratory, neurological or liver disease,
• Patients with immunosuppression related to malignancy, use of immunosuppressive drugs, HIV infection or other diseases like diabetes.
• Morbid obesity
On an average, about half of hospitalized patients have had at least one or more underlying medical conditions. One third of patients with very severe illness admitted to ICU are previously healthy persons.
Patients with uncomplicated influenza may have symptoms of influenza-like illness that may or may not be associated with gastrointestinal
symptoms:
• Influenza-like illness symptoms: Fever higher than 38oC, cough, sore throat, rhinorrhea, headache, muscle pain, malaise, but no shortness of breath, no dyspnoea. Patients may present with some or all of these symptoms.
• Other possible symptoms may include headach, myalgia, joint pain and malaise
• Gastrointestinal illness may also be present, such as diarrhoea and/or vomiting, especially in children, but without evidence of dehydration.
Dr. Prashant nasa Md
Dr. Rajesh Chawla Md FCCM
Indraprastha Apollo Hospitals, Delhi
Signs and symptoms of progressive disease:
Patients who present initially with uncomplicated influenza may progress to more severe disease. The following are some of the indicators of progression, which would necessitate an urgent review of patient management:
• Symptoms and signs suggesting oxygen impairment or cardiopulmonary insufficiency:
- Shortness of breath (with activity or at rest), difficulty in breathing, turning blue, bloody or coloured sputum, chest pain, and low blood pressure;
- Hypoxemia, as indicated by pulse oximetry.
• Symptoms and signs suggesting CNS complications: Altered mental status, unconsciousness, drowsiness, or difficult to awaken and recurring or persistent convulsions (seizures), confusion, severe weakness, or paralysis.
• Evidence of sustained virus replication or invasive secondary bacterial infection based on laboratory testing or clinical signs (e.g. persistent high fever and other symptoms beyond 3 days).
• Severe dehydration, manifested as decreased activity, dizziness, decreased urine output, and lethargy.
Point to ponder:
• Most have a history of flu-like illness (fever, sore throat and cough) but this may be mild prior to developing signs of severe acute respiratory infection.
• Some may deteriorate rapidly.
13The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
• Although most have respiratory symptoms, some have signs of dysfunction in other systems (e.g. nausea, vomiting, diarrhea, abdominal pain, encephalopathy).
• Rarely, patients may present with only abdominal or CNS symptoms.
• Cases with asthma, or who are pregnant, or morbidly obese more likely to require critical care.
• Despite children having high attack rates, at present the proportion requiring ICU admission is low at present the proportion requiring ICU admission is low.
Laboratory Confirmation:
Real-time RT-PCR is the recommended test for confirmation of cases. It has a sensitivity of 90-100% with different methods. At this stage of the pandemic, the test is not required to be done on all cases and would be highly recommended in the following situations:
• Uncomplicated influenza patients in the presence of one or more of the risk factors.
• All patients with complicated influenza
The positivity of the test would determine the treatment options of the patient.
Anti viral agents: Whom to Treat?
Antiviral treatment is recommended at this stage of the epidemic to the following groups:
• Uncomplicated influenza patients with the presence of one or more of the risk factors
• All patients with complicated influenza whether there is a risk factor or not.
Population Pandemic (H1N1) influenza virus 2009
Multiple co-circulating influenza A sub-types or viruses with different antiviral susceptibilities
Mild to moderate uncomplicated clinical presentation
At-risk population oseltamivir or zanamivir Zanamivir, or oseltamivir plus M2 inhibitor
Otherwise healthy Need not treat Need not treat
a. Amantadine should not be used in pregnant women
Severe or progressive clinical presentation
At-risk population Oseltamivir (zanamivir should be used where virus is known to be resistant to oseltamivir, or if oseltamivir unavailable)
oseltamivir plus M2 inhibitor or zanamivir
Otherwise healthy
Antiviral Dosing:
Under no circumstances should influenza diagnostic testing delay initiation of infection control practices or antiviral treatment, if pandemic (H1N1) 2009 disease is suspected clinically and epidemiologically.
The following table indicates the recommended dosing for oseltamivir and zanamivir in adults and children:
Agent Group Treatment (5 days) Prophylaxis (10 days)
Oseltamivir
Adults 75 mg twice daily 75 mg once daily
Children > 12
months
≤ 15 kg 30 mg twice daily 30 mg once daily
16 to 23 kg 45 mg twice daily 45 mg once daily
24 to 40 kg 60 mg twice daily 60 mg once daily
>40 kg 75 mg twice daily 75 mg once daily
Zanamivir
Adults 10 mg (2 inhalations)
twice daily
10 mg (2 inhalations)
once daily
Children 10 mg (2 inhalations)
twice daily (7 years
and older)
10 mg (2 inhalations)
once daily (5 years
and older)
Patients who have severe or progressive clinical illness should be treated with oseltamivir. Treatment should be initiated as soon as possible.
• This recommendation applies to all patient groups, including pregnant women, and young children <2 years, including neonates.
• In patients with severe or progressive illness not responding to normal treatment regimens, higher doses of oseltamivir and longer duration of treatment may be appropriate. In adults, a dose of 150 mg twice daily for 10 days is being used in these situations.We have been giving higher doses to patients admitted in ICU. Dose adjustment is required for Cr Clearance < 30ml/min. There are insufficient safety data for doses higher than 75mg twice daily in pregnancy.
• Where oseltamivir is not available or not possible to use, or if the virus is resistant to oseltamivir, patients who have severe or progressive clinical illness should be treated with zanamivir.
Infection control
Evidence to date suggests that pandemic (H1N1) 2009 virus is transmitted similarly to seasonal influenza A and B viruses. Appropriate infection control measures (Standard plus Droplet Precautions) should be adhered to at all times. Aerosol-generating procedures are:
• Intubation and related procedures: manual ventilation
• Respiratory and airway suctioning including tracheostomy care
• Nasogastric aspiration
• Cardiopulmonary resuscitation
• Bronchoscopy
• Autopsy
When performing aerosol-generating procedures health-care providers should be aware that these procedures have been associated with increased risk of infection transmission and precautions should include the following:
• Hand hygiene before and after patient contact, and immediately after removal of mask.
• Facial particulate respirator (e.g. EU FFP2, US NIOSH-certified N95)
• Eye protection (i.e. goggles or a face shield)
14• Clean, non-sterile long-sleeved gown
• Gloves (some of these procedures require sterile gloves)
• Perform procedures in an adequately ventilated room (>12 air changes per hour)
• Avoid permitting unnecessary individuals into the room.
Antimicrobial treatment:
No role of routine antimicrobials. However, seasonal influenza and past influenza pandemics have been associated with an increased risk of secondary Staphylococcus aureus infections, which may be severe, rapidly progressive, necrotizing, and, in some occasions, caused by methicillin-resistant strains. The following table may help when to start antimicrobials in these patients.
Indications of the Etiology or Etiologies of Pneumonia in Patients with Influenza-Related Lower Respiratory Tract Disease.*Indication Primary Influenzal
Lower Respiratory Disease
Secondary Bacterial Pneu-monia Following Influenza
Identification of influenza +++ ++; lower rate of recovery because later in illness
Fever +++ +++; secondary fever after a period of defervescence
Diagnostic specimen from lower respiratory tract (sputum specimen, tracheal aspirate, specimen obtained on bronchoscopy or intuba-tion)
Normal flora Gram’s stain or culture shows predominant organism (Strepto-coccus pneumonia, Staphylococcus aureus, Streptococcus pyogenes, Hemophilus influenza, Moraxella catarrhalis)
Patients with progressive pandemic (H1N1) disease may deteriorate very rapidly (within hours) and require close observation and rapid interventions. Treatment of ARDS associated with the new influenza A (H1N1) virus infection should be based upon published, evidence-based guidelines for sepsis-associated ARDS.
• Standard lung-protective ventilation strategies (pressure/volume-limited ventilation) are appropriate initially.
• In highly resourced settings where very specialized intensive-care technologies are available, individual patients with refractory hypoxemia have benefited from negative fluid balance, prone positioning, and advance respiratory support such as nitric oxide, high frequency oscillation (HFO), and/or extracorporeal membrane oxygenation (ECMO). Such rescue therapies should be considered only if the treating physician/facility has established experience in these modalities.
• We highly recommend a conservative fluid strategy in 2009 H1N1 ARDS patients in the absence of hypotension, dehydration or the need for early goal directed therapy.
NIV GUIDELINES FOR H1N1 (European Respiratory Society and European Society of Intensive Care Medicine, oct 2009)
NIV may be considered
• Mild to moderate hypercapnic acute respiratory failure, acute respiratory failure and/or distress due to cardiogenic pulmonary
edema in the absence of pneumonia,multiple organ failure or, refractory hypoxemia.
• Post-extubation respiratory failure in patients with resolving ARDS secondary to H1N1 infection, preferentially when the patient is no longer contaminated.
When NIV MUST NOT be considered-
• Rapid development of ARDS, with often very severe hypoxemia and large intrapulmonary shunts.
• Those patients with H1N1 infection admitted to ICU with multiple organ failure and/or refractory hypoxaemia,
As a general rule, NIV is not recommended as an alternative to invasive ventilation for patients affected by H1N1.
Steroids Therapy
There is an evidence of increased viral replication in SARS and other respiratory viral infections in patients on steroids. There is evidence that steroids may be detrimental in 2009 H1N1 influenza and is associated with increased mortality. However in a recently published small trial by Dr. G. Umberto Meduri ,11 of 13 patients showed a marked improvement in lung injury scores by day 7, and the in-hospital mortality rate was lower than expected in such a critically ill population on steroids.
On the basis of these findings and the extensive basic science rationale supporting prolonged steroid therapy in acute respiratory distress syndrome, the French Ministry of Health has announced it will fund a randomized controlled trial of this treatment protocol in patients with H1N1 influenza–associated ARDS, Low Doses Corticosteroids as Adjuvant Therapy for the Treatment of Severe H1N1 Flu (CORTIFLU).
However, the results won’t be in until after the current seasonal outbreak of 2009 H1N1 flu has ebbed, according to Dr. Meduri of the University of Tennessee, Memphis.
Although Dr. Meduri’s protocol originally called for reserving methylprednisolone for patients with severe ARDS and using hydrocortisone at 300 mg/day in the others, he now believes it’s simpler to use methylprednisolone in all patients, bearing in mind that those with severe ARDS need higher doses.
He recommends in a patient with severe ARDS; the methylprednisolone dose is 1 mg/kg/day, tapered as detailed in his earlier randomized trial involving patients with early severe ARDS unrelated to H1N1 flu (CHEST April 2007; 131:954-63).
Acute Kidney Injury
Impairment of renal function is common. Approximately 20% of critically ill H1N1 patients may require renal replacement therapy. The presence of acute renal failure is associated with higher risk of death with an Odd Ratio of 25.Thromboembolic prophylaxis
Critically ill patients with 2009 H1N1 disease is at higher risk of developing thromboembolic disease and is very Important to ensure that prophylaxis is prescribed.
Resources
• http://www.cdc.gov/h1n1flu/
• Clinical management of human infection with pandemic (H1N1) 2009: revised guidance (WHO November 2009
• Clinical Management protocol and Infection Control Guidelines (Ministry of health and family welfare,Government of India)
• When to Consider the Use of Antibiotics in the Treatment of 2009 H1N1 Influenza–Associated Pneumonia. NEJM. Vol 361:e112, 2009.
15The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine
Significance of arterial hypotension after resuscitation
from cardiac arrest
Clinical practice guideline: Red blood cell transfusion in adult
trauma and critical care
Family satisfaction in the intensive care unit: what makes
the difference?
Assessing pain in non-intubated critically ill patients unable to
self report: an adaptation of the Behavioral Pain Scale
Evaluation of “Loss” and “End stage renal disease” after acute
kidney injury defined by the Risk, Injury, Failure, Loss and
ESRD classification in critically ill patients
Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly
reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials
Why we should be wary of single-center trials
Stephen Trzeciak, Alan E. Jones, J. Hope Kilgannon, et al. Crit Care Med, November 2009; 37:2895-2903Expert guidelines advocate hemodynamic optimization after return of spontaneous circulation (ROSC) from cardiac arrest despite a lack of empirical data on prevalence of post-ROSC hemodynamic abnormalities and their relationship with outcome. Our objective was to determine whether post-ROSC arterial hypotension predicts outcome among postcardiac arrest patients who survive to intensive care unit admission.Cohort study utilizing the Project IMPACT database (intensive care unit admissions from 120 U.S. hospitals) from 2001-2005, One hundred twenty intensive care units. Inclusion criteria were: 1) age ≥18 yrs; 2) nontrauma; and 3) received cardiopulmonary resuscitation before intensive care unit arrival.Subjects were divided into two groups: 1) Hypotension Present-one or more documented systolic blood pressure <90 mm Hg within 1 hr of intensive care unit arrival; or 2) Hypotension Absent-all systolic blood pressure ≥90 mm Hg. The primary outcome was in-hospital mortality. The secondary outcome was functional status at hospital discharge among survivors. A total of 8736 subjects met the inclusion criteria. Overall mortality was 50%. Post-ROSC hypotension was present in 47% and was associated with significantly higher rates of mortality (65% vs. 37%) and diminished discharge functional status among survivors (49% vs. 38%), p < .001 for both. On multivariable analysis, post-ROSC hypotension had an odds ratio for death of 2.7 (95% confidence interval, 2.5-3.0).Half of postcardiac arrest patients who survive to intensive care unit admission die in the hospital. Post-ROSC hypotension is common, is a predictor of in-hospital death, and is associated with diminished functional status among survivors. These associations indicate that arterial hypotension after ROSC may represent a potentially treatable target to improve outcomes from cardiac arrest.
transfusion in adult trauma and critical care will provide important information to critical care practitioners.
inter-rater reliability (weighted kappa coefficient = 0.89 for the four conditions and 0.82 during nociceptive procedures) and a good responsiveness, with an effect size ranging from 1.5 to 3.6.Pain during procedures is perceived even in non-intubated ICU patients with delirium. In those patients, pain level can be assessed with the BPS-NI scale since this instrument exhibited good psychometric properties.
Rodrigo Cartin-Ceba, Eric N. Haugen, Remzi Iscimen, et al. Intensive Care Med, December 2009; 35:2087-2095The Risk, Injury, Failure, Loss and ESRD (RIFLE) classification has been widely accepted for the definition of acute kidney injury (AKI); however, no study has described in detail the last two stages of the classification: “Loss” and “ESRD”. We aim to describe and evaluate the development of “Loss” and “ESRD” in a group of critically ill patients.We conducted a retrospective analysis of cases prospectively collected from the Acute Physiology and Chronic Health Assessment (APACHE III) database. Subjects were consecutive critically ill patients >18 years of age admitted to three ICUs of two tertiary care academic hospitals, from January 2003 through August 2006, excluding those who denied research authorization, chronic hemodialysis therapy, kidney transplant recipients, readmissions, and admissions for less than 12 h for low risk monitoring.11,644 patients were included in the study. The median age was 66 (interquartile range, 52–76), 90% were Caucasians and 54% of the patients were male. Half of the patients developed AKI, and most of the patients were in the Risk and Injury stages. From the patients that developed AKI, a total of 1,065 (19%) patients required renal replacement therapy (RRT), 415 (39%) underwent continuous renal replacement therapy (CRRT) and 650 (61%) underwent intermittent hemodialysis. A total of 281 patients on RRT did not survive hospital discharge, 97 patients progressed to “Loss”, and 282 patients progressed to “ESRD”. After multivariable adjustment, the progression to “ESRD” was associated with higher baseline creatinine, odds ratio (OR) 1.19 per every increase in creatinine of 0.1 mg/dl (95% CI, 1.11–1.29) P < 0.001; and less frequent use of CRRT, OR 0.18 (95% CI, 0.11–0.29) P < 0.001.In this large retrospective study we found that almost 50% developed some form of AKI as defined by the RIFLE classification. Of these, 19% required RRT, and 4.9% progressed to “ESRD”. “ESRD” was more likely in patients with elevated baseline creatinine and those treated with intermittent hemodialysis.
Gordon S. Doig, Philippa T. Heighes, Fiona Simpson, et al. Intensive Care Med, December 2009; 35:2018-2027To determine whether the provision of early standard enteral nutrition (EN) confers treatment benefits to critically ill patients. Medline and EMBASE were searched. Hand citation review of retrieved guidelines and systematic reviews were undertaken and academic and industry experts were contacted.Methodologically sound randomised controlled trials (RCTs) conducted in critically ill patient populations that compared the delivery of standard EN, provided within 24 h of intensive care unit (ICU) admission or injury, to standard care were included.The primary analysis was conducted on clinically meaningful patient-oriented outcomes. Secondary analyses considered vomiting/regurgitation, pneumonia, bacteraemia, sepsis and multiple organ dysfunction syndrome. Meta-analyses were conducted using the odds ratio (OR) metric and a fixed effects model. The impact of heterogeneity was assessed using the I2 metric.Six RCTs with 234 participants were analysed. The provision of early EN was associated with a significant reduction in mortality [OR = 0.34, 95% confidence interval (CI) 0.14–0.85] and pneumonia (OR = 0.31, 95% CI 0.12–0.78). There were no other significant differences in outcomes. A sensitivity analysis and a simulation exercise confirmed the presence of a mortality reduction.Although the detection of a statistically significant reduction in mortality is promising, overall trial quality was low, trial size was small, and the findings may be restricted to the patient groups enrolled into included trials. The results of this meta-analysis should be confirmed by the conduct of a large multi-centre trial enrolling diverse critically ill patient groups.
Rinaldo Bellomo, Stephen J. Warrillow and Michael C. Reade Crit Care Med, December 2009; 37:3114-3119To highlight the limitations of single-center trials in critical care, using prominent examples from the recent literature; to explore possible reasons for discrepancies between these studies and subsequent multicenter effectiveness trials; and to suggest how the evidence from single-center trials might be used more appropriately in clinical practice.Topical and illustrative examples of the concepts discussed including trials of patient positioning, the use of steroids for acute respiratory distress syndrome, the dose of hemofiltration, the control of glycemia, and the targets of resuscitation in sepsis.Many positive single-center trials have been contradicted when tested in other settings and, in one case, the subsequent definitive multicentered trial has found a previously recommended intervention associated with active harm. Problems inherent in the nature of single-center studies make recommendations based on their results ill advised. Single-center studies frequently either lack the scientific rigor or external validity required to support widespread changes in practice and their premature incorporation into guidelines may make the conduct of definitive studies more difficult.We recommend that practice guidelines should rarely, if ever, be based on evidence from single-center trials. Physicians should apply the findings of single-center trials only after careful evaluation of their methodology, and in particular after comparing the context of the trial with their own situation.
Kay H. Stricker, Oliver Kimberger, Kurt Schmidlin, et al. Intensive Care Med, December 2009; 35:2051-2059To assess family satisfaction in the ICU and to identify parameters for improvement. Multicenter study in Swiss ICUs. Families were given a questionnaire covering overall satisfaction, satisfaction with care and satisfaction with information/decision-making. Demographic, medical and institutional data were gathered from patients, visitors and ICUs.A total of 996 questionnaires from family members were analyzed. Individual questions were assessed, and summary measures (range 0–100) were calculated, with higher scores indicating greater satisfaction. Summary score was 78 ± 14 (mean ± SD) for overall satisfaction, 79 ± 14 for care and 77 ± 15 for information/decision-making. In multivariable multilevel linear regression analyses, higher severity of illness was associated with higher satisfaction, while a higher patient:nurse ratio and written admission/discharge criteria were associated with lower overall satisfaction. Using performance-importance plots, items with high impact on overall satisfaction but low satisfaction were identified. They included: emotional support, providing understandable, complete, consistent information and coordination of care.Overall, proxies were satisfied with care and with information/decision-making. Still, several factors, such as emotional support, coordination of care and communication, are associated with poor satisfaction, suggesting the need for improvement.
Lena M. Napolitano, Stanley Kurek, Fred A. Luchette, et al. Crit Care Med, December 2009; 37:3124-3157To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members.This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM.Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion.Evidence-based recommendations regarding the use of RBC
Gérald Chanques, Jean-François Payen, Grégoire Mercier, et al. Intensive Care Med, December 2009; 35:2060-2067To validate an adaptation of the Behavioral Pain Scale (BPS) for its use in non-intubated intensive care unit (ICU) patients unable to self-report their pain because of the occurrence of delirium. The “vocalization” domain was inserted to construct the BPS-non intubated (BPS-NI) scale, ranging from 3 (no pain) to 12 (most pain).Prospective psychometric study in a medical-surgical ICU. The same physician and one bedside nurse rated pain in non-intubated patients unable to self-report their pain during four conditions: before and after a catheter dressing change (non-nociceptive procedure) and before and after turning the patient (nociceptive procedure). Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU).A total of 120 paired evaluations were performed in 30 consecutive adult patients, 84% with delirium (CAM-ICU positive). BPS-NI scores were higher during painful procedures than at rest [6.0 (5.0–8.0) vs. 3.0 (3.0–3.8); P < 0.001], while no changes in BPS-NI scores were found during non-nociceptive procedures (discriminative validity). The BPS-NI had good internal consistency (standardized Cronbach α = 0.79), and each domain reflected the pain expression factor in a balanced way (coefficients between 0.57 and 0.59). The BPS-NI had a good
Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center
databaseThomas V. Brogan, Ravi R. Thiagarajan, Peter T. Rycus, et al. Intensive Care Med, November 2009; 35:2105-2114To evaluate clinical and treatment factors for patients recorded in the Extracorporeal Life Support Organization (ELSO) registry and survival of adult extracorporeal membrane oxygenation (ECMO) respiratory failure patients. Retrospective case review of the ELSO registry from 1986–2006. Data were analyzed separately for the entire time period and the most recent years (2002–2006).1,473 patients, 50% survived to discharge. Median age was 34 years. Most patients (78%) were supported with venovenous ECMO. In a multi-variate logistic regression model, pre-ECMO factors including increasing age, decreased weight, days on mechanical ventilation before ECMO, arterial blood pH ≤ 7.18, and Hispanic and Asian race compared to white race were associated with increased odds of death. For the most recent years (n = 600), age and PaCO2 ≥ 70 compared to PaCO2 ≤ 44 were also associated with increased odds of death. The two diagnostic categories acute respiratory failure and asthma compared to ARDS were associated with decreased odds of mortality as was venovenous compared to venoarterial mode. CPR and complications while on ECMO including circuit rupture, central nervous system infarction or hemorrhage, gastrointestinal or pulmonary hemorrhage, and arterial blood pH < 7.2 or >7.6 were associated with increased odds of death.Survival among this cohort of adults with severe respiratory failure supported with ECMO was 50%. Advanced patient age, increased pre-ECMO ventilation duration, diagnosis category and complications while on ECMO were associated with mortality. Prospective studies are needed to evaluate the role of this complex support mode.
Impact of acute hypercapnia and augmented positive end-expiratory pressure on right
ventricle function in severe acute respiratory distress syndrome
Armand Mekontso Dessap, Cyril Charron, Jérôme Devaquet, et al.
Intensive Care Med, November 2009; 35:1850-1858
To evaluate the effects of acute hypercapnia induced by positive end-expiratory pressure (PEEP) variations at constant plateau pressure (Pplat) in patients with severe acute respiratory
Assessment of Pro-Vasopressin and Pro-Adrenomedullin as
Predictors Of 28-Day Mortality In Septic Shock Patients
Initiation of Inappropriate Antimicrobial Therapy Results in
a Fivefold Reduction of Survival in Human Septic Shock
ICU Admissions after Actual or Planned Hospital Discharge:
Incidence, Clinical Characteristics, and Outcomes in Patients with
Cancer
Sedative Use during Continuous Positive Airway Pressure Titration Improves Subsequent Compliance:
A Randomized, Double-Blind, Placebo-Controlled Trial
Acute Pancreatitis and Critical Illness:
A Pancreatic Tale of Hypoperfusion and Inflammation
Coagulopathy in Critically Ill Patients:
Part 1: Platelet Disorders
Dose-Dependent Benefit of Nitroglycerin on Microcirculation
of Patients with Severe Heart Failure
Christopher J. Lettieri, Jacob F. Collen, Arn H. Eliasson, et al.
Chest, November 2009; 136(5):1263–1268
The initial experience with continuous positive airway pressure (CPAP) may predict subsequent compliance. In
Sarah E. Greer , Kenneth W. Burchard.
Chest, November 2009; 136(5):1413–1419
Since it was first widely recognized at the end of the 19th century, acute pancreatitis has proven a formidable clinical challenge, frequently resulting in management within critical care settings. Because the early assessment of severity is difficult, the recognition of severe acute pancreatitis (SAP) and the implementation of critical care treatment precepts often are delayed. Although different management strategies for life-threatening features of SAP have been debated for decades, there has been little recent reduction in mortality rates, which can be as high as 30%. This article discusses severity designation at the time of diagnosis, reviews the pathophysiologic mechanisms so well characterized by the noxious combination of severe systemic inflammation and hypoperfusion, and provides a management algorithm that parallels current critical care strategies.
Todd W. Rice , Arthur P. Wheeler.
Chest, December 2009; 136(6):1622–1630
Abnormalities of platelet number and function are the most common coagulation disorders seen among ICU patients. This article reviews the most frequent causes of thrombocytopenia by providing an overview of the following most common mechanisms: impaired production; sequestration; dilution; and destruction. Guidelines for treating thrombocytopenia and platelet dysfunction are also provided.
Corstiaan A. den Uil, Kadir Caliskan, Wim K. Lagrand, et al.
Intensive Care Med, November 2009; 35:1893-1899
Microcirculatory abnormalities are frequently observed in patients with severe heart failure and correlate to worse outcomes. We tested the hypothesis that nitroglycerin dose-dependently improves perfusion in severe heart failure and that this could be monitored by measuring central-peripheral temperature gradient and with Sidestream Dark Field imaging of the sublingual mucosa.
A dose-response study was performed in 17 patients with cardiogenic shock (n = 9) or end-stage chronic heart failure (n = 8) admitted to Erasmus University Medical Center. We did hemodynamic measurements at baseline and during increasing infusion rates of nitroglycerin (up to a maximum dose of 133 μg min−1). As parameters of tissue perfusion, we measured central-peripheral temperature gradient (delta-T) and sublingual perfused capillary density (PCD).
Nitroglycerin dose-dependently decreased mean arterial pressure (p < 0.001) and cardiac filling pressures (both central venous pressure (CVP) and pulmonary capillary wedge pressure: p < 0.001). It increased cardiac index (p = 0.01). Nitroglycerin decreased delta-T (p < 0.001) and increased sublingual PCD (p < 0.001). Significant changes in delta-T and PCD occurred earlier, i.e., at a lower doses of NTG, than changes in global hemodynamics. Macrohemodynamic and microcirculatory responses to nitroglycerin infusion were consistent in patients with either cardiogenic shock or end-stage chronic heart failure. Changes in microcirculatory parameters occurred independently of changes in cardiac index.
Nitroglycerin dose-dependently increases tissue perfusion in
Caroline Guignant, Nicolas Voirin, Fabienne Venet, et al.
Intensive Care Med, November 2009; 35:1859-1867
Improvements in survival after septic shock will most likely rely on our capacity to manage individualized therapies based on the measurement of rapidly accessible biomarkers. As the early phase of septic shock is dominated by severe alterations of the cardiovascular system, the predictive value for mortality of pro-vasopressin (pro-AVP) and pro-adrenomedullin (pro-ADM), two vasoactive pro-hormones, was assessed.
In 99 consecutive patients, pro-hormone concentrations were measured (immunoluminometric assay) three times within the first week after the onset of septic shock. Pro-AVP and pro-ADM concentrations were significantly increased in non-survivors in comparison with survivors and were significantly associated with mortality after both univariate and multivariate analysis. Importantly, when assessed as a pair, pro-ADM and pro-AVP were even more informative.
Both Pro-ADM and pro-AVP appear to be good biomarkers for the prediction of 28-day mortality after septic shock. However, their association in a single variable tends to improve their predictive capacity.
Anand Kumar, Paul Ellis, Yaseen Arabi, et al.
Chest, November 2009; 136(5):1237-1248
Our goal was to determine the impact of the initiation of inappropriate antimicrobial therapy on survival to hospital discharge of patients with septic shock.
The appropriateness of initial antimicrobial therapy, the clinical infection site, and relevant pathogens were retrospectively determined for 5,715 patients with septic shock in three countries.
Therapy with appropriate antimicrobial agents was initiated in 80.1% of cases. Overall, the survival rate was 43.7%. There were marked differences in the distribution of comorbidities, clinical infections, and pathogens in patients who received appropriate and inappropriate initial antimicrobial therapy (p < 0.0001 for each). The survival rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively (odds ratio [OR], 9.45; 95% CI, 7.74 to 11.54; p < 0.0001). Similar differences in survival were seen in all major epidemiologic, clinical, and organism subgroups. The decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal infection to 17.6-fold with primary bacteremia. After adjustment for acute physiology and chronic health evaluation II score, comorbidities, hospital site, and other potential risk factors, the inappropriateness of initial antimicrobial therapy remained most highly associated with risk of death (OR, 8.99; 95% CI, 6.60 to 12.23).
Inappropriate initial antimicrobial therapy for septic shock occurs in about 20% of patients and is associated with a fivefold reduction in survival. Efforts to increase the frequency of the appropriateness of initial antimicrobial therapy must be central to efforts to reduce the mortality of patients with septic shock.
Sanjay Chawla, Stephen M. Pastores, Kashif Hassan, et al.
Chest, November 2009; 136(5):1257–1262
Unexpected ICU admissions may result from early or premature discharge from the hospital. We sought to determine the incidence, clinical characteristics, and outcomes of patients admitted to the ICU after actual or planned hospital discharge and to analyze whether the need for ICU admission was related or unrelated to the associated hospitalization.
We retrospectively reviewed all adult ICU admissions between January 2004 and December 2006 at a tertiary care cancer center and identified the following two groups of patients: those patients admitted directly to the ICU within 48 h of actual hospital discharge (group A); and those patients admitted to the ICU within 48 h of planned hospital discharge (group B).
60,462 patients discharged from the hospital during the study period, 826 patients (1.4%) required readmission to the hospital within 48 h of discharge; of these, 13 patients (1.5%) were admitted directly to the ICU (group A). An additional 12 patients were admitted to the ICU within 48 h of a planned hospital discharge (group B). The majority of these 25 patients (68%) [groups A and B] required ICU admission for a condition that was related to the previous or current hospitalization. The overall hospital mortality rate for both groups was 16%.
Conclusions: A small, but unique group of patients is admitted to the ICU within 48 h of actual or planned hospital discharge. Worsening of the underlying condition that necessitated the previous or current hospitalization often is the reason for ICU admission. Whether ICU admission could have been prevented by continued hospital care or improved diagnostic evaluation during the prior or current hospitalization requires further study.
patients with severe heart failure, as observed by a decrease in central-peripheral temperature gradient and an increase in sublingual perfused capillary density
Journal Scan dr. Sudha Kansal dr. Prashant Nasa
dr. Shreikanth Sriniwasan
Dept of Critical Care Medicine,Indraprastha Apollo Hospitals, New Delhi
distress syndrome (ARDS) on right ventricular (RV) function.
Prospective observational study in two academic intensive care units enrolling 11 adults with severe ARDS (PaO2/FiO2 <150 mmHg at PEEP >5 cmH2O). We compared three ventilatory strategies, each used for 1 h, with Pplat at 22 (20–25) cmH2O: low PEEP (5.4 cmH2O) or high PEEP (11.0 cmH2O) with compensation of the tidal volume reduction by either a high respiratory rate (high PEEP/high rate) or instrumental dead space decrease (high PEEP/low rate). We assessed RV function (transesophageal echocardiography), alveolar dead space (expired CO2), and alveolar recruitment (pressure–volume curves).
Compared to low PEEP, PaO2/FiO2 ratio and alveolar recruitment were increased with high PEEP. Alveolar dead space remained unchanged. Both high-PEEP strategies induced higher PaCO2 levels [71 (60–94) and 75 (53–84), vs. 52 (43–68) mmHg] and lower pH values [7.17 (7.12–7.23) and 7.20 (7.16–7.25) vs. 7.30 (7.24–7.35)], as well as RV dilatation, LV deformation and a significant decrease in cardiac index. The decrease in stroke index tended to be negatively correlated to the increase in alveolar recruitment with high PEEP.
Acidosis and hypercapnia induced by tidal volume reduction and increase in PEEP at constant Pplat were associated with impaired RV function and hemodynamics despite positive effects on oxygenation and alveolar recruitment (ClinicalTrials.gov #NCT00236262).
a retrospective study, we found that premedication with nonbenzodiazepine sedative-hypnotic agents during CPAP titration polysomnography independently predicted short-term compliance. To validate these findings, we conducted a prospective clinical trial to assess whether premedication with eszopiclone prior to CPAP titration would improve short-term CPAP compliance.
Subjects in this randomized, double-blind, placebo-controlled trial received 3 mg of eszopiclone or matching placebo prior to undergoing CPAP titration polysomnography. We compared the quality of CPAP titrations and objective measures of compliance during the first 4 to 6 weeks of therapy between the two groups.
We enrolled 117 subjects, and 98 subjects completed the protocol (eszopiclone, 50 subjects; placebo, 48 subjects). Other than there being more women in the eszopiclone group, the groups were similar at baseline. Compared with placebo, premedication with eszopiclone significantly improved mean (± SD) sleep efficiency (87.8 ± 5.8% vs 80.1 ± 10.5%, respectively; p = 0.002) and mean total sleep time (350.9 ± 33.6 min vs 319.7 ± 48.7 min, respectively; p = 0.007). A trend toward improved sleep latency (19.4 ± 16.1 min vs 31.8 ± 30.4 min, respectively; p = 0.08) and the number of residual obstructive events observed at the final CPAP pressure (6.4 ± 7 events/h vs 12.8 ± 14.6 events/h, respectively; p = 0.08) during polysomnography was found. Eszopiclone significantly improved CPAP compliance. Among subjects premedicated with eszopiclone, CPAP was used on a higher percentage of nights (75.9 ± 20.0% vs 60.1 ± 24.3%, respectively; p = 0.005) and for more hours per night (4.8 ± 1.5 h vs 3.9 ± 1.8 h, respectively; p = 0.03).
Premedication with eszopiclone on the night of CPAP titration improved the quality of CPAP titration and led to significantly greater short-term compliance (ClinicalTrials.gov Identifier: NCT00507117).
