Update in Intensive Care - Home - ANZCA · 2018-11-12 · Update in Intensive Care Australasian Perioperative Medicine Symposium Melbourne 2018. Our background. ... TAVR is associated

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


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


L2 – ≥ 6 beds200 MV/yr

L3 – ≥ 8 bedsLong term

care

QLD/NSW/SA


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)


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


Question

Elective Admission to ICU/HDU

Carotid Endarterectomy?


Thyroidectomy?

Parathyroidectomy?


Gastric Bypass surgery (laprascopic)?

Uvuloplasty for OSA?

Craniotomy – excision of Meningioma?


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




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)



Service GoalsPreoperative optimisation

Facilitation of early rehabilitationDischarge planning

Supporting ceiling of careEnd of Life decision making



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


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


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)


As SpO2 increases, mortality increases


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)



Is there a SaO2 “sweet spot”?94-96%

Is it the FiO2?


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


Hospital Mortality = 10%

Septic Shock

Vasopressor requirementpost fluid resuscitation

Lactate > 2mmol/L


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


Deep SedationProne

ParalysisRecruitment

ECMOHFOV

?NO?Prostacycline


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


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


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?

Documents

Update in Intensive Care - Home - ANZCA · 2018-11-12 · Update in Intensive Care Australasian Perioperative Medicine Symposium Melbourne 2018. Our background. ... TAVR is associated