State of the Art 2019

Day 2

Dan Horner, Consultant in Emergency Medicine and Intensive Care at Salford Royal Hospital and Chris Gray, ST6 in EM at Manchester Royal, St Emlyn's bloggers, take a look at day two of SOA 19.


Onwards to day 2 then, and how better to break your fast than with some EVIDENCE. Lovely. Today’s scientific discourse came courtesy of 6 big names and focussed on fluid therapy, blood pressure targets and vasoactive agents. How much is enough, what’s the magic number and which type is best. If only we could solve all that in 90 minutes

Fluids first and we started with a case vignette. The speakers pounced on the fact that only 10% of the audience voted for 30mls/kg in an elderly hypotensive patient with pneumonia, despite international guidelines promoting the same.

Anders Perner touched on some data in press from a systematic review suggesting current evidence shows no clear mortality benefit to liberal fluid therapy in adult patients with sepsis. Small numbers though, or ‘paltry’ data as described by John Myburgh. A relevant trial (CLASSIC) has reported feasibility data already and is recruiting at present. Seems to be increasing agreement in the room that less is possibly more with regard to fluid therapy. Which timepoints in care to target then? A nod to the knock on issue of flow and the problem of wards/emergency departments giving ‘just a bit more fluid’ as a band aid, while awaiting an ICU bed. We can all intervene on this – it just requires sensible care and advice. Then an interesting discussion about the occult crime of ‘maintenance’ fluids on the ICU, leading to significant daily overload and often unrelated to any physiological benefit. Just stop it.

MAP targets next, which opened with the caveat that 65 trial results won’t be out until next year (shame). Then another clinical vignette poll, which split the audience between opting for a MAP target of 65-70 (around 50%) or a target of 60-65 (around 35%). Why do we care about MAP at all? We heard some compelling arguments that less might be more again and our obsession with specific numbers may well be detrimental. Always vital to consider the nuance of your individual patient, disease and your clinical objectives. We then heard about data from a recent individual patient data meta-analysis comparing higher versus lower targets in septic and vasodilatory shock. The take home? Targeting higher BP targets may actually increase mortality. Lower targets do not seem to result in worse outcomes, even in the chronically hypertensive. Seems to be a theme in this session (and intensive care in general….).

Vasoactives to finish this track and the first case vignette asked the audience when they would start something in a 70 year old patient with septic shock and community acquired pneumonia. A more even split here, with half wanting 30mls/kg prior, a quarter happy to start immediately and a quarter wanting at least 1L in. But how to give - peripheral or central? And what to give? Tony Gordon talked about the evidence base here, discussing CENSER and the currently recruiting CLOVERS trial, both looking at very early use of vasopressors. CENSER in particular also seems to suggest that peripheral administration of dilute noradrenaline is feasible, does not result in higher adverse event rates and can be managed within a lower acuity environment. This would definitely decrease time to pressor commencement – one wonders how much additional data is needed before this finds a way to established UK practice? Next up, a brief discussion on the available ‘fudge’ agents such as oral midodrine, peripheral metaraminol, phenylephrine, terlipressin etc.. Interesting stuff, very little comparative evidence, clear suggestion from the panel of international variation in practice.

Next, a discussion on what to do when a reasonable amount of fluid filling and noradrenaline is not enough? A real audience split here between adding in vasopressin, increasing catecholamines, or measuring cardiac output and looking towards an inotrope. We heard about a recent systematic review suggesting that there is some evidence to support adjunctive vasopressin in reducing adverse event rates, particularly AF and potentially renal replacement therapy. A caution followed on the risks of polypharmacy. I’m a big fan of objective cardiac output monitoring prior to a second agent, but clearly this was not standard practice in the room… Time for a coffee everyone.

Next session was the Cauldron and all speakers were tendering for use of $1million dollar charitable funds. First Eleanor Damm asked us if our house was on fire? Is it? I’ve not been home all week, now I’m worried….

Climate change is a clear global emergency and high up on everyone’s agenda. This is of course highly likely to impact healthcare, for numerous reasons. We have to ask ourselves, how can we as healthcare professionals mitigate the issue? Proposed solutions included the following via the remit of cathedral thinking: appoint a sustainability consultant intensivist, for example; we are good at attention to detail and engaging colleagues. Encourage the hospital board to declare a climate emergency. Address procurement and waste; develop sustainable or recyclable options for anything and everything. Sustainable packaging. Vegan food options. Green spaces. Transport options. All good ideas.


Next, in an apparent swing shift, Rachel Jones asked us if we wanted to spend the money on champagne? ‘Of course we do’ we cried, but how will that help our patients? Well, apparently this may address three of our big problems in critical care; the mental health of our long stay patients; the morale of staff; the increasing spend on locum bank staff. Health care professionals have been making champagne for centuries apparently. Give Rachel a pump priming bid and she’ll make us a garden, then a vineyard, then a fruitful enterprise… Interesting stuff. We even had a bit of evidence. We’d all want to go to work if our M&M took place in an idyllic vineyard. Why not spend a million on it? Lots of chin scratching.

After that, plan A was bonefish cay. Or burnout, in other words. We heard about the Maslach inventory and we also heard that 25% of intensivists will experience PTSD, or depression, or both. Clearly a huge issue for all of us. But how will throwing money at the problem solve the issue? That’s where bonefish cay comes in – a multidisciplinary rest and rehabilitation experience. At only 800K? Lovely. But the real plan proposed was multifactorial – a mental health psychologist to be established on every intensive care unit; green spaces, gardens and mindfulness areas; wellbeing champions with a clear strategy for improving working environments; Schwartz rounds; a plug for civility saves; peer to peer mentoring via programmes like WARD; cheeseboards, mainly to facilitate team lunches and group networking. All good ideas, but followed by an excellent question from the Dragons about the issue of secondary prevention; what about primary initiatives? How can you identify and mitigate the developing symptoms of burnout in a chronically underfunded and understaffed NHS? Difficult. I’m biased, but I would highlight that current research is trying to address this in emergency medicine and has reached write up stage.

Then the crystal ball was out, via Eleanor Richards. How can we make anticipatory decisions about admission to intensive care? How can money help? Well, why not build a pre-ICU department? An area to set up, staff and publicise a service to simplify and improve admission decision making. How would this work? We were treated to a walkthrough via theme hospital, which started with a referral process. Those patients with comorbidity, non-compliance or functional limitations could be referred through a variety of access modes. Step 2 would be an appointment with a suitable senior intensivist, with an introduction and discussion as to what ICU actually entails. Step 3 would then be an MDT discussion and provision of a transparent care plan based on patient preference and clinical opinion. A lot of good stuff here, but the panel worried about further algorithmic care, scalability, lack of community engagement and the inevitable ethical concerns of disagreements in appropriate levels of care.

Last up we were asked to support a rebranding exercise by Guy Parsons. The Intensive Care Unit is dead; long live the Intensive and Palliative Care Unit (IPCU). The suggestions followed that we actively mislead patients with a name like ICU, when around 30% of our patients die, and we actively get it wrong when we are asked to try and decide who might die, and when. We were asked to introduce palliative care into our immediate care planning, perhaps even in the daily care bundles. We were asked to highlight compassion towards patients and relatives from day 1. This concept of concurrent palliative care has been around for a while and is a very compelling one. But where is the money going? The suggestions were for embedded palliative care nursing staff, embedded fellowships and cash for new digs. Within the latter aspect, Guy asked for more beds, natural light, music, ambience, individual rooms and many other things that could make a hospital more hospitable. There was even a suggestion that this activity could become cost neutral in the long run, due to reduced clinical interventions, earlier identification of terminal conditions, improved dialogue with families and other multiple benefits. All quite compelling really. And as such, he only went and won it. Well done Guy.

All great talks, from enthusiastic and highly engaging speakers. I love the cauldron. Long may it continue.

After lunch, a series of tech talks. Who doesn’t love a tech talk at an ICU conference?

A discussion on AI from a self confessed tech geek and ICU consultant first up, which started with an interesting focus on how technology is most likely to impact healthcare. Will it help us diagnose? Will it help us with predictive language? Willi it help predict individual patient responses to medication? Will it help us predict outcome over time? Will it help us decide between the age old argument of fluids and pressors….? If it solved the latter problem, I might begin to like it. Watch this space/screen.

Next up our very own RB talking about tomorrow’s medicine today. He led with an example on how technology might impact the management of a simple OOHCA. Poor old George. Why didn’t his smart watch automatically detect a rhythm incompatible with life and summon a 999 response direct to his GPS location? Why didn’t his watch trigger a community response via the Goodsam app? Could drone technology dispatch a defibrillator? And then in hospital – can Alexa run the code? Although this stuff is all available now, why don’t we use it already? Because apparently, it takes over 17 years for new tech to make it through to frontline care in the NHS. Can we do better? Rick thinks we should change three things

We heard again about how p-values are wrong and how perhaps we should try to understand the potential impact of machine learning and augmented decision making in different ways. Lots of narrative discussions here around how we can assess care, prompt considered reflection, develop critical reflexivity and how (and where) we get the aha moment.

Then a disruptive final session via @drmolsg. Some telling examples of EPR failing, or switchboard averaging 17 minutes to answer a call. The induction app certainly speaks to the junior doctor in me who remembers struggling for the blood bank phone extension at 4am while looking at a monitored heart rate of 140….

Last session of the day – TRAUMA. A packed hall awaited and we started with an emotive reminder of what trauma can look like and mean to many of us, highlighted by recent events in London.

Claire Park told us about the medical and tactical aspects affecting the outcome from terrorist incidents. It’s not just the medical issues, but often the tactical area and access to resource that can be a major issue. A recap of hot zones (armed police), warm zones (limited healthcare resources) and cold zones. We then heard about ‘care under fire’ techniques for first aid provision in the hot zone, with regard to rolling prone to allow postural airway drainage and simple tourniquet application. The military experience was highlighted over a decade, with reference to exsanguinating haemorrhage at compressible sites. We then heard about developments to address it, such as <C> starting to be the first letter of the alphabet.

Then onto non compressible haemorrhage – what to do about this? Well, whatever we do, we need to do it quickly. Hence the principle of incident response teams, medical emergency response teams, helicopter emergency medicine teams and so on and so forth. Likewise for prehospital blood products. We also touched on the importance of human factor issues with this type of care, via the Yerkes-Dodson curve. Claire finished with a discussion on how important it is to psychologically process involvement in medical trauma care like this, following military deployment, or terrorist incident.

St Emlyns took to the stage again after, via Zaf Qasim. A discussion that Zaf is well placed to lead on started, regarding the differences in trauma care between the UK and US. Then we were onto what to do if you get 7 GSW alerts in a row.

Public involvement got a shout again, with Zaf highlighting the induction of accessible bleeding kits in some US states and the key need to empower bystanders to deliver time critical intervention. Prehospital care appears to be a bit more disparate with limited physician presence in the field. However, the police are getting involved and appear now to have a role in both initial medical first aid and conveyance. Speed is of the essence, and supported by the evidence.

We then heard a bit about trauma centre care, secondary transfer, skill maintenance, whole blood and of course (it’s Zaf) REBOA. Critical care differences were perhaps more interesting, with mention of a role for vasopressin based on recent study and ECMO for significant and complex injury, or traumatic cardiac arrest. Last, a note on performance and standards. How do we all stay good? A nod to the importance of teamwork, peer review, video feedback, open reflection and critical discussion of team performance in regular M&M. Good stuff which we at StE have always championed.

Ceri Battle next, discussing her decade long journey of experience in blunt chest wall trauma. We heard about the NEXUS rule for chest imaging, how to use different scoring systems to direct management, what to do for multimodal analgaesia and who to operate on. Lots of ongoing questions here and lots of grey areas. But also lots of ongoing research, which is encouraging. Physiotherapy and rehabilitation is also key after the acute period, which the relevant UK societies are supporting and Ceri has just completed a pilot feasibility study on this. Really impressive stuff and we are all grateful in the UK that Ceri has plowed on as a clear national champion for these patients.

Tim Coates to close. Is major trauma now 2 entirely different diseases? Yes, he thinks so. So does TARN. So do I, as a practicing trauma team leader at a busy centre. What’s the problem? Well, trauma triage simply does not work with low energy transfer major trauma patients in the elderly. And the knock on effects of this can hugely impact on outcome. What to do about it? I’m not sure anyone knows the practicalities of this, but Tim seems to have a clear vision of integrated trauma centre care, revolving around hub and spoke models and powered by easy access to diagnostic imaging, frailty scoring and comprehensive geriatric assessment in local centres. Some challenging questions from the audience; isn’t this just a way of MTCs politely declining complex referrals? How should trauma care be remunerated nationally? Do you really have the TARN data from general hospitals and trauma units to support this theory of dual cases. An interesting discussion to close on, and one that will continue.

Another great day, well curated and well delivered. Time for a curry now. See you in the morning. If you’re going to the party, throw some shapes on my behalf. Some of us have to be up early…..

Dan