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Post Resuscitation CareDr Ian Seppelt
Senior Specialist in Intensive Care Medicine, Nepean Hospital
Senior Research Fellow, George Institute for Global Health,
University of Sydney
(an introduction to basic intensive care medicine)
• 95% of intensive care medicine is “getting the basics right”
• The other 5% is picking up the ….
The other 5% is picking up the ….
Post Resuscitation Care
1. General care– Fluid Management– Pain, sedation, delirium– Nutrition– Blood sugar control
2. Post cardiac arrest– Therapeutic hypothermia– Prognosis after cardiac arrest
Where are we heading with intensive care research?
There are no magic bullets• It is implausible that any treatment will reduce
mortality by 14%• The attributable mortality of sepsis is about 10%
[Bellomo, ANZICS APD, 2010]
• We can realistically expect an effect size of 1-2%
• What costs < $2,500/patient in ICU– Better fluid therapy or fluid balance management,– Better transfusion practices, – Better nutrition, – Better sedation– Better oxygen therapy– Better fever management,– Better setting of the ventilator knobs etc. etc.
With thanks to Prof Rinaldo Bellomo
Where are we heading with intensive care research?
Getting the basics right
Not too much, not too little, but
just right
Fluid Management
1. It’s not what you use but how you use it– No evidence of benefit for any one fluid over
another
2. Treat patient not numbers– Warm, well perfused, conscious, passing urine
3. Too much fluid as harmful as not enough
Single centre unblinded study by an enthusiast …
With an implausible outcome ……
And a huge effect on emergency medicine and intensive care practice
ARISE Observational Cohort study
• 32 sites, 324 patients, same inclusion criteria as Rivers
• Mortality– ICU 18.9% (n = 58)
– Hospital 20.1% (n = 62)
– 28-day 22.2% (n = 72)
– EGDT Study 46.5% standard arm, 30.5% EGDT arm
Arterial line 44.4%
CVC 37.0%
ScvO2 line 0%
NA or Ad 29.9%
Blood 7.7%
Hct T0hr 37 (19 - 66)
Hct T6hr 33 (19 – 48)
Dobutamine 2.5%
Inv Vent 18.8% ARISE interventions
T0 toT6 hr
1550 (0 - 9030) ml
412 (0 – 3500) ml
Fluids
Median,range
Arterial line 44.4%
Std 100%, EGDT 100%
CVC 37.0%
Std 100%, EGDT 100%
ScvO2 line 0%
Std 0% EGDT 100%Total fluids 2431 (1951) ml
Na or Ad 29.9%
Blood 7.7%
Dobutamine 2.5%
Inv vent 18.8% HOW DO WE COMPARE TO
the EGDT study?
Std 3499 (2438) ml
EGDT 4981 (2984) ml
Std 30.3%, EGDT 27.4%
Std 18.5%
EGDT 64.1%
Std 0.8%, EGDT 13.7%
Std 53.8%
EGDT 53.0%
Mean(SD)
Three large international trials now underway
• ARISE (Australia and New Zealand)
• PROMISE (United Kingdom)
• PROCESS (USA)
Message no 1
• A single centre trial by an enthusiast should not change practice …..
• …… no matter how good the results are ……• until it has been validated in a multicentre
environment• How do the results apply to YOU in YOUR
hospital?
Fluid Management - Summary
• Resuscitation fluid as necessary• After resuscitation, titrate fluid as necessary to
CLINICAL end points• Too much fluid can harm
– Tissue edema, organ failures– Pulmonary edema, ventilation failure
• Beware the ‘accidental’ fluids
Pain, sedation, delirium
• Three separate concepts which should be managed separately [2012 SCCM guidelines]
• Many ICU patients just need pain relief– Usually an opioid, by bolus or infusion
• If agitated, look for the cause– Uncomfortable or itchy– Full bladder?
Sedative drugs
• Growing evidence that benzodiazepines cause long term problems– Neuropsychological problems– Post traumatic stress disorder
• Increased volume of distribution and impaired clearance in critical illness– Midazolam is not a ‘rapid offset’ drug after an
infusion
Sedative drugs
• Sedative doses should be minimized to achieve a goal of light sedation– Calm but responsive to voice– Regular assessment of sedation depth– Consider daily interruption of sedation
• Delirium– Non drug approaches?– Specific drug therapy for delirium
• Observational cohort study in Australian, New Zealand, Malaysia
• Planning large RCT comparing an ‘anti delirium’ sedation protocol with usual practice
Extubation Time Mortality
26Wean ventilation as clinically tolerated and proceed to Extubation once clinically feasible
InterventionarmTitrate to maintain
RASS -2 to +1
RASS Q 4 hrs
CAM-ICU daily / twice
Dexmedetomidine
Conventional arm
Propofol
Morphine or fentanyl
Expected Ventilated > 24 hours, Sedation / Opioids
Randomise
Dependent on baseline care from
observational study for drugs and trials
Breakthrough agitation
Breakthrough delirium
Breakthrough agitation
Breakthrough delirium
Sedation - Summary
• Think about Pain, Agitation, Delirium as three different concepts, all treated differently
• Patient safety comes first• Calm and cooperative patient ideal• Excessive sedation associated with longer time
on ventilator, longer time in ICU, post-traumatic stress disorder, and possibly increased mortality
Nutrition
• Any patient expected to be in the ICU “the day after tomorrow” needs nutrition– Commence feeds within 24 hr in this group
• Enteral is best – cheapest, most physiological
• Parenteral nutrition reserved for those who cannot tolerate enteral– expensive, risk of sepsis
• Need unit guidelines– Specific to your own environment and casemix– Even with guidelines, only expect 70 – 80%
compliance• Don’t forget nutritional deficiencies
– Thiamine
Nutrition
Blood sugar control
• Hyperglycemia is common in critical illness, and associated with worse outcomes
• ‘Intensive insulin control’• Large influence from single centre SICU study
in Belgium (van den Berghe, NEJM 2001)• Results not duplicated in MICU study
Blood sugar control - summary
• Single centre results could not be duplicated in large multicentre study
• ‘Intensive insulin therapy’ caused increased mortality
• Keep BSL in ‘high normal’ range– 6.0 – 10.0 mmol/l or– 110 – 180 mg/dl
Post Cardiac Arrest Management
Return of spontaneous circulation – what next?
Post cardiac arrest
• Emergency angiography and stenting?– Depends on local resources– Otherwise consider thrombolysis according to usual
criteria• Cardiogenic shock
– No clear benefit of any one inotrope or vasopressor– Titrate to physiological goals– Physical therapies (positive end expiratory pressure,
IABP)
Therapeutic hypothermia
• We know that HYPERthermia is bad in brain injury
• Two trials suggest neurological benefit with either 12 or 24 hours moderate hypothermia– 32 to 34oC– Ice packs, cold fluids, cooling jackets
• ILCOR recommendation• Adverse effects of hypothermia
– Coagulation, electrolytes, cardiac function
TTM trial
Comparison of hypothermia with NORMOthermiaafter cardiac arrest?
Summary - hypothermia
• Fever is bad in brain injury• Likely benefit of hypothermia in subgroups
studied– Don’t forget exclusions– VF/VT cardiac arrest only– Not cardiogenic shock– Problems with drug metabolism – suppresion on
hepatic metabolism
Prognosis after cardiac arrest
• Used to be relatively simple– Levy criteria (JAM 1985)– No chance of regaining independence:
• No pupillary light reflex• 24 hr motor response worse than flexor and no
coordinated eye movements• 3 day motor response no better than flexor• 1 week not obeying commands ….
Wijdicks et al, Neurology 2006;67:203–210
Wijdicks et al, Neurology 2006;67:203–210
Prognosis in Hypothermia Era
• None of the ‘old’ tests validated• Confounded by need for sedation to tolerate
hypothermia– Too much sedation, slow metabolism, saturation
of fat stores• Evidence that therapy is being withdrawn too
son in patients with a good prognosis• But how long to wait?
PROPAC II
• Multicentre prospective cohort study in Netherlands to investigate the reliability of prognosis after cardiac arrest treated woth hypothermia
• Diagnostic methods – neurological examination,– neuron specific enolase (NSE) – median nerve somatosensory evoked potentials (SEP)
• Outcome– 53% poor outcome; patients die in first week
• Prediction poor outcome– Absent brain stem reflexes FPR 1 – NSE > 33μg FPR 7-10– SEP normothermia FPR 0
Conclusions – Post Resuscitation Intensive Care
Conclusions - 1
• ‘Not too much, not to little, but just right’• Be cautious applying magic therapies from
single centre studies elsewhere in the world• Know your own environment, epidemiology
and resources
Conclusions - 2
• After resuscitation over, give just enough fluid to achieve clinical endpoints– Too much fluid as bad as not enough– Choice of fluid much less important
• Sedate intelligently– Treat pain, agitation and delirium separately– Oversedation harmful
Conclusions - 3
• Early nutrition recommended– Use enteral route if possible – Don’t forget thiamine and treat other nutritional
deficiencies• Keep blood sugar ‘high normal’
Conclusions - 4
• Post resuscitation from cardiac arrest– Treat the heart as indicated (PTCA or thrombolysis)– Hypothermia for subgroup of patients shown to
benefit– Adverse effects of hypothermia– Be very careful with drugs and hypothermia
Conclusions - 5
• Prognosis after cardiac arrest is really hard in the hypothermia era
• Make no decisions until– Normothermia– You are confident of drug clearance
• Compassionate approach to patient and family in social context
Questions?