Webinar 2016 Sepsis Guidelines ESICM

Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants

Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants https://t.co/oTvhHIDTbJ pic.twitter.com/0VQ3S22orA

— Critical Care (@Crit_Care) February 15, 2017

Link of the article to my ReadCube

Should We Intubate During In -Hospital Cardiopulmonary Resuscitation: Conventional Wisdom vs Big Data

Intubation during arrest was associated with worse outcomes.

The 2015 American Heart Association Advanced Cardiovascular Life Support guidelines deemphasize advanced airway placement as a component of initial resuscitation. Out-of-hospital–arrest data suggest lower survival among patients who are intubated in the field (NEJM JW Emerg Med Feb 2013 and JAMA 2013; 309:257). To determine whether this applies to in patients, investigators examined resuscitations of more done 108,000 patients in a US registry.

Seventy percent of patients were intubated during their code events; most (95%) of these intubations occurred within 15 minutes of resuscitation. Patients with initial nonshockable rhythms (i.e., pulseless electrical activity [PEA] or asystole) were more likely to be intubated than were those with ventricular fibrillation or tachycardia (69% vs. 53%).

In a time-matched propensity analysis, patients who were intubated during resuscitation were significantly less likely to survive to discharge than those who were not (16% vs. 19%) and were less likely to be discharged with good functional status (11% vs. 14%). In subgroup analyses, associations between intubation and these outcomes were not seen in patients who had preexisting respiratory insufficiency but were more pronounced for patients with initial shockable rhythms.

Comment by Patricia Kritek, MD. , American College of Chest Physicians (Critical Care Board Review Course):

This observational study raises important questions about an established practice: Attempt at intubation can interrupt chest compressions or slow defibrillation, potentially delaying these life-saving interventions, particularly for patients with ventricular fibrillation or tachycardia.  However the results still could be confounded by underlying differences between the intubated and non-intubated groups that were not captured by the statistical technique of propensity matching.  Therefore, I am not ready to abandon efforts to intubate patients with in-house arrest, especially those with PEA or asystole moreover, when respiratory failure is the cause of an arrest, early advanced airway management is important as a potential remedy to the underlying pathophysiology.

The accompanying editorial in JAMA  is enlightening and highlights the pitfalls, but also the strengths of this analysis.

Is There Any Benefit at all to Hypothermia in In-Hospital Cardiac Arrest

Data from a large cohort examining the the benefit of hypothermia in adult in- hospital arrest found no benefit. As a matter of TTM( targeted temperature management) was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of a favorable neurological outcome in both shockable and non- shockable rhythms . An RCT is certainly warranted in this group. The data are consistent with a prospective study in the pediatric population ( the latter did have a major flaw of initiating TTM on average 5 hours after ROSC )

Association Between Therapeutic Hypothermia and Survival After In-Hospital Cardiac Arrest

No Benefit from Therapeutic Cooling After Pediatric In-Hospital Cardiac Arrest

One-year outcomes were similar with therapeutic hypothermia or therapeutic normothermia.

The efficacy of therapeutic hypothermia (target temperature, 33.0°C) versus therapeutic normothermia (target temp 36.8°C) in improving outcomes after out-of-hospital cardiac arrest in children is similar in clinical trials. To compare the efficacy of these interventions after in-hospital pediatric cardiac arrest, researchers randomized 329 children aged 48 hours to 18 years to either intervention (maintained for 120 hours) after in-hospital arrest.

The primary outcome was 12-month survival with favorable neurobehavioral outcomes. All participants had previously normal neurobehavioral assessment, received chest compressions for at least 2 minutes, and remained dependent on mechanical ventilation after return of circulation.

There were no between-group differences in the primary outcome, and the rates of survival at 12 months between the hypothermia and normothermia groups were also similar (49% and 46%, respectively). The trial was stopped after a review of interim efficacy results due to an assessment of futility.

COMMENT

Despite these authors' valiant attempt to control the therapeutic interventions, some variables might have affected the outcomes. For example, it took approximately 5 hours to initiate the interventions after the return of circulation. Would outcomes have been different if the interventions had been carried out more quickly? Are these target temperatures the correct ones? 

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children

Lower Oxygen Saturation Goals Are Safe in Mechanically Ventilated Patients

Targeting to 88%–92% did not cause harm.

The optimal oxygenation goal for patients who are receiving invasive mechanical ventilation remains unclear. Clinicians usually target resolution of hypoxemia and pay little attention to weaning levels of oxygen once 100% saturation has been achieved. However, harms caused by hyperoxia, including effects on cardiac function and lung parenchyma, are of concern.

To assess the safety of a lower oxygenation target, investigators randomized 104 patients who were receiving invasive mechanical ventilation to either a conservative strategy (peripheral oxygen saturation, 88%–92%) or a liberal strategy (peripheral oxygen saturation, >95%) for the duration of ventilator support. Positive end expiratory pressure (PEEP) levels were determined by treating physicians who were not blinded to the intervention. Three quarters of enrolled patients had medical diagnoses. Mean fraction of inspired oxygen (FiO2) at randomization was 0.44.

No differences were detected between groups in organ dysfunction or mortality. Mean saturation in the conservative arm was 93.4% (vs. 97.0% for the liberal arm), and more arterial blood gases were drawn. These two findings suggest some clinician discomfort with targeting lower oxygen saturation levels. Patients in the conservative arm were more likely to have episodes of severe desaturation, although these events were rare in both groups.

This study reassures us that a lower oxygen saturation target is not harmful. Whether this practice confers benefit is unclear, but these results should allow researchers to comfortably conduct larger randomized, controlled trials with lower oxygen saturation goals.

Conservative versus Liberal Oxygenation Targets for Mechanically Ventilated Patients. A Pilot Multicenter Randomized Controlled Tria

Surviving Sepsis - Guidelines 2016

A lot has been written about this and this is not hot of the press , but the video gives a nice summary and comparison with the previous guidelines

The 2012 versus the 2016 Guidelines Video

A User Guide to the 2016 Surviving Sepsis Guidelines

Webinar from ESICM on Hypothermia post Cardiac Arrest: 33 vs 36 degrees ..or just fever control?

Interesting how we change our minds after a one hour lecture. The original 33 degree Hypothermia trial had a major flaw: the control arm had a high incidence of uncontrolled fever, common post cardiac arrest. Not exactly the control group you want. 
I suspect ultimately fever control is all that is needed , but device therapy will likely accomplish this better then medical therapy alone.

Setting up APRV on the PB 840 Ventilator

I have been so used working with the Drager ventilator where setting the Phigh and Plow, as well as Thigh and Tlow is easy and intuitive.  However in other ventilators particular in the Puritan-Bennett 840 you  have to go into settings and use the locks to demonstrate your T low.  
Every time I camera in and asked a respiratory therapist,  they state that they cannot set T low . This not the case . Also the difference adding PSV is that you have to subtract the difference between Phigh and Plow and then add PS to the pressure difference to set the level of PS you want. This is explained pretty well in the video. Also RR has to be kept between 6-12 BPM ( look at Thigh and Tlow when changing this)  and PEFR can be nicely demonstrated, magnified in freeze frame mode. I: E ratio becomes totally irrelevant when PSV is added.


Here is a good summary overview on how to manipulate the various parameters :

APRV Management

Discussion high Tv and lung protective strategy in APRV

APRV  discussion