Critical Care Global Grand Rounds

As technology and medicine progress so do our options for care. But how does doing ‘what we can' impact the ‘doing what is right'? How often do pressures related to the job cause us to act in ways that are inconsistent with our ethical values? How does that impact us and what can we do to minimise its effect?

In this talk, Andrew will review the latest evidence on brain monitoring in TBI. Does aggressive brain monitoring impact outcomes, and how? Do aggressive therapies to lower raised ICP impact outcomes, and by how much? And what is the future of brain monitoring?

Organ transplantation using organs donated after death is now the preferred treatment for many end-stage organ failures and is life-changing and life saving for recipients. Outcomes from transplantation are excellent, for example a third of liver transplant recipients are alive 30 years following transplant. Unfortunately, the demand for donor organs outstrips supply. This talk reviews current practice and recommendations.

Coming soon

Acute Kidney Injury (AKI) affects nearly 40% of intensive care unit (ICU) patients and carries significant morbidity and mortality. Once AKI is established, renal replacement therapy (RRT) is the mainstay of supportive care. The best time to initiate RRT is still unclear. Although several studies have evaluated early vs. late RRT in AKI, there is no clear consensus on how “early” or “late” should be defined. Existing evidence does not support the initiation of RRT based on any particular stage of AKI. Risk-benefit of RRT along with the host's ability to tolerate homeostatic derangements should be taken into account prior to initiating RRT. Continuous RRT (CRRT) has not been shown to be superior to intermittent hemodialysis (IHD). A CRRT dose of at least 20ml/kg/hour or an IHD dose of Kt/V 1.2 thrice a week seems to be adequate for patients with AKI in the ICU. Improvement of urine output and trend in azotemia can serve as a guide in weaning and termination of RRT. Diuretics have not been shown to decrease the need or frequency of RRT.  

Diarrhoea is a prominent cause of morbidity and mortality in children under 5 years in lower to middle-income countries (LMICs). Current recommendations for intravenous rehydration are based on limited evidence. This talk covers the epidemiology and management of gastroenteritis and examines the latest studies and their implications for practice.

Non-invasive oxygenation strategies include standard oxygen therapy, non-invasive ventilation, and high-flow nasal oxygen. Non-invasive ventilation in turn may be delivered via a helmet or a face-mask interface. When deployed for the treatment of acute hypoxemic respiratory failure, on average, all these strategies reduce the risk of intubation and may reduce the risk of all-cause mortality. In addition, when used upon extubation, they appear to reduce the risk of re-intubation in adult critically ill patients. In this setting, it may be especially useful to use both high flow nasal oxygen and non-invasive ventilation. This talk will not describe the use of non-invasive ventilation for classic indications such as acute exacerbation of chronic obstructive pulmonary disease or congestive heart failure.

Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients is often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes effective, low-cost and low-complexity care for the identification and treatment of critically ill patients across all medical specialties. The content of EECC has recently been specified in a global consensus process. Implementing EECC could be an effective and cost-effective strategy for policy-makers, hospital managers and clinicians to reduce preventable deaths worldwide.

Medical practices at the end of life differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination.  In Europe and other regions of the world, patient-physician relationships are still somewhat paternalistic. Different cultures and countries deal in diverse ways with the ethical dilemmas arising as a consequence of the wider availability of life-sustaining therapies. In the past patients died in intensive care units (ICUs) despite ongoing aggressive therapy. Over the years, observational studies documenting physician behavior have noted changes in the modes of patient deaths and an earlier limitations of life-sustaining treatments. This lecture will review the current global practices.

This talk focuses on ways in which clinical trials in critical care medicine are evolving. Such evolutions include individual patient-level meta-analyses, registry trials, cluster trials, cluster crossover trials, cluster crossover registry trials, and Bayesian trials.

Clinical trials in critical care medicine are challenging to conduct and can be difficult to interpret. This talk will focus on some common problems encountered in clinical trial design and when evaluating big data. In particular, the talk with describe the concept of base-rate neglect and the difficulty with drawing causal inferences from observational analyses using big data.

Safety-critical industries require accurate task performance that is often multifaceted and reliant on time-sharing between concurrent tasks. Clinical tasks often involve multiple sensory modalities. Some of these tasks are auditory, such as spoken communication with a team and detecting auditory alarms, and some tasks contain additional visual components, such as ascertaining vital signs. The auditory domain is under considerable pressure in clinical work. Noise levels in the clinical realm have become a problem in clinical environments, where they have gradually risen over the last few decades. Noise, or competing and unwanted sounds, are a particular challenge in healthcare. The World Health Organization (WHO) recommends nighttime noise levels in hospitals not exceed 30dB, yet the average nighttime level has been found to be much higher, typically at 60dB. The overall noise level in hospital settings (alarms and non-alarms), including the OR, can be detrimental to both patient recovery and clinician performance. Aside from their loudness, the nature of clinical audible alarms is undergoing considerable change since evidence has emerged that the tonal style of alarms, particularly those advocated in the medical device global safety standard, IEC 60601-1-8, are difficult to learn and recognize. In addition to auditory medical alarms, research in the domains of neuroscience, psychology, biomedical engineering, and human factors engineering is striving to develop optimal multisensory (auditory, visual, haptic) alarms to improve patient care and attenuate fatigue.

Perioperative handoffs, also known as handovers or signouts, are patient care transitions between clinicians or teams. They represent breaks in the continuity of care that have ability to introduce error, increasing the risk of adverse patient outcomes. Handoffs can be improved through standardization, which makes information transfer more reliable by scripting the interactions between care team members. Standardizing perioperative handoffs from the operating room (OR) to the intensive care unit (ICU) is associated with improved handoff quality and patient outcomes, but changing clinician behavior is not always straightforward. In this talk, Dr. Meghan Lane-Fall describes the potential risks associated with OR to ICU handoffs, proven strategies for improving them, and the use of implementation science to promote the uptake of standardized handoffs.

Research and clinical practice in the field of early physical rehabilitation for critically ill patients is a dynamic field with evolving evidence from randomized controlled trials. Many studies have demonstrated the safety and feasibly of early rehabilitation interventions in the ICU, with improved patient outcomes. Consequently, international clinical practice guidelines support ICU-based physical rehabilitation. Further research is required to refine existing knowledge to identify which patients will benefit the most; determine optimal timing, duration, and type of intervention; understand potential synergistic effects with light sedation and nutritional interventions; and standardize assessment of patient outcomes.

Coming Soon

The quality of survival for patients after intensive care unit (ICU) admission is a major health challenge that has been described as the defining challenge for critically ill in the 21st century. ICU survivors may have delayed and compromised functional recovery, which can persist for months or years. Preliminary evidence suggests critically ill patients admitted to ICU who are expected to require prolonged mechanical ventilation may benefit from early activity and mobilisation. However, the type of activities, the timing of the intervention and an effective dose remains unclear. This talk will review the latest evidence.

The pandemic has brought the ICU medical ethics of decision making and resource management into the public arena. We have also witnessed suffering in ICU staff from moral distress at unprecedented levels. What ethical lessons has the pandemic taught us? Can we promote ethical discourse that is balanced, insightful and helpful and resist the bad and the ignorant? How do we stop those who promulgate moral panic, drawbridge ethics and magic number ethics? Can we find MORAL Balance? Yes, we can, let us show you how.

COVID19 survivors suffer from persistent respiratory symptoms and functional limitations after the acute infection. Longitudinal studies after SARS-CoV2 infection showed impairment in lung function exercise capacity and Lung imaging abnormalities. In this lecture, we review possible post covid pulmonary involvement with a focus on whether they develop fibrosis. We also review the latest evidence on the long term follow up. Possible treatment strategies are discussed including antifibrotic therapy, mesenchymal cell therapy, prolonged steroids therapy and pulmonary rehabilitation. We conclude with recommendations for pulmonary follow up and post covid clinic design.

Most ICU doctors think they are good communicators. Maybe you are. Maybe you are not. But all of us can be better communicators. In this talk, we will share our experience in leading UK ICU teaching in breaking bad news and organ donation conversations. We'll break some myths, share some approaches – including a structured approach which we call 'Breaking bad news as a Shakespearean tragedy' – and warn you of common pitfalls. But being a better communicator yourself is just a start. As ICU leaders how do you formally teach and debrief communication? We want to complete the circle and finish the session by helping you become communication leaders and teachers.

Acute on chronic liver failure (ACLF ~ cirrhosis with multiorgan failure) is associated with significant morbidity and mortality. ACLF require ICU admission often for vasopressor support, intubation/mechanical ventilation for acute lung injury/hepatic encephalopathy and renal support for acute kidney injury often as a bridge to listing and receipt of a liver transplant. This lecture will review the definition of ACLF, discuss organ system management and discuss current challenges in getting these patients through a successful liver transplant.

Palliative care is a field of medicine that focuses on (among other things) symptom management, and communication and support. Palliative care principles have relevance throughout the ICU continuum, from serious illness prior to ICU admission, to the ICU itself, and into the bereavement period. In this lecture, we will review the ways in which the principles of palliative care can be integrated into the care of the critically ill, and look at some of the important studies of palliative care interventions in the ICU environment.

Malnutrition is a major global health problem. Childhood malnutrition increases the risk of morbidity & mortality and has been shown to underlie almost half of the total number of deaths in children less than 5-years. In this lecture, we will review cardiac function and fluid resuscitation in critical illness states among severely malnourished children.

Acute muscle wasting occurs rapidly in the critically ill patient, at rates of 2-3% per day, and is associated with levels of organ failure. Muscle wasting is associated with adverse outcomes at all stages of critical illness and critical illness recovery, affecting mortality up to 1 year later. Altered muscle protein homeostasis (and specifically depressed muscle protein synthesis) underpins this process and is in turn underpinned by bioenergetic failure and intramuscular inflammation. This talk will cover the underpinning biology, the potential role of exercise and nutrition in amelioration and treatment, and several ongoing trials in the field of acute muscle wasting.

In the last five years, the introduction of cellular therapies has revolutionized the management of haematological cancers. The success of this approach has encouraged others to seek novel means to treat a variety of critical illness syndromes. In this talk, we will review the current state of cell-based immune modulation for ARDS and sepsis. We will address the classification and biology of investigational cell therapies, alongside a discussion of the challenges associated with scaling them for widespread clinical use.

In this lecture, we will review the changing incidence, complexity, therapies and prognosis of patients with cancer who become critically ill.

The management of anaemia is a cornerstone of critical care practice, but how certain are we of the relationship between red blood cell transfusion practices and patient outcomes?  And, what else, beyond transfusion thresholds, should clinicians be considering when deciding how best to manage anaemia in the intensive care unit?

Bone loss is an under-recognised sequela of critical illness and its consequences are underappreciated. Apart from fragility fractures in the months following ICU discharge with the associated morbidity and mortality, acute bone loss may contribute to and perpetuate organ dysfunction in critical illness. This talk will explore these concepts, summarise the available literature and discuss ways in which bone loss and its effects might be mitigated. This is an exciting field for future research in times where the focus is to enable our patients to thrive, not just survive their critical illness.

Acute liver failure (ALF) is a rare syndrome resulting from an acute insult to the liver in patients without known underlying chronic liver disease. It is characterized by loss of synthetic function in the form of jaundice and coagulopathy and the development of hepatic encephalopathy. Multiorgan-failure (MOF) eventually develops. Significant improvements in outcome have occurred over the last 50 years, resulting not only from incremental improvements in specialist critical care and a step-change following the introduction of transplantation for this indication but also better and more effective treatment started early at the site of first presentation.

Traditional ideas around the meaning of death have been altered irrevocably by technological advances from the mid-20th century. Modern definitions of death are problematic both technically and conceptually, and have been subjected to numerous legal challenges, especially in the USA. Studies by a number of groups, including our own, suggest that family decisions about organ donation place most importance on prognosis and consent, rather than the presence of death. Some authors have suggested that, contrary to what is assumed, principles such as the ‘Dead Donor Rule’ serve mainly to provide comfort for participating doctors, and are ethically unnecessary. Organ donation and the diagnosis of death remain ethically controversial in the 21st century.

This talk will discuss the prevalence of pain in the critically ill population, risk factors for developing pain in the ICU, and validated ways to diagnose and measure it. It will cover the short and long-term outcomes of pain in the ICU and finally will go over recommendations for treatment and prevention.

The SARS-CoV-2 pandemic has heightened public frustration with the importance of controlling integration of medical research into practice, despite the social media immediacy, sensationalism and inappropriate dissemination of conflicting, frequently incorrect and misinterpreted clinical outcomes. The importance that new, evolving knowledge may displace and refute earlier management strategies is highlighted. Discussion will reinforce current evidence based medical practice as an essential framework on which effective translational research can be accomplished despite pandemic imposed challenges.

A summary of steroid use in sepsis and the latest evidence-based recommendations.

The treatment of pain is an essential component of the care of critically ill patients. Opioids are a mainstay of this care in the ICU, used for both analgesia and sedation. However, recent trends in the overall use of opioids in the population have raised concerns regarding the potential for acute exposure to lead to long-term dependence or abuse. This talk will review the current evidence for best use of opioids in the ICU and address the concern as to whether exposure during critical illness may impact long-term prescribing.

A talk summarising the important aspects of EEG for the acute care physician.

Physiological facts:  Haemodynamics are complex and represent a teleological neurohormonal response to stress.   Defence of MAP represents the balance between the afferent and efferent circulations and the compliance of the system.  Monitoring is an aid to an overall assessment that must be considered within the clinical context and patient’s trajectory of illness.  Pharmacological facts:  Catecholamines are hormones that are administered to augment inadequate endogenous responses. Synthetic catecholamines have no established role in clinical practice. Neurohormonal supplementation strategies have limited roles and should be confined to indications established from RCTs. Non-catecholamine inodilators have not been demonstrated to improve patient-centred outcomes in critically ill patients.

Stress ulcer prophylaxis is given commonly to patients in the ICU. However, the choice of which type or drug to use for this purpose or whether widespread use of ulcer prophylaxis is justified is debated. This talk will review current evidence in relation to stress ulcer prophylaxis in the ICU focusing on the recently published PEPTIC trial.

The practice of medicine and healthcare, in general, is a fusion of art and science. The art of medicine relies on often intangible and unquantifiable components such as common sense and experience. The science of medicine arises from the conduct and interpretation of research which should be scientifically valid, quantifiable and applicable to the patient in front of you. Unfortunately, much research is poorly conducted, poorly analysed, poorly presented, and often interpreted by researchers who have a vested interest in the results. Understanding the ever-expanding methods used in clinical research in general, and particularly in critical care is essential to providing your patients with the best and most appropriate care. Fortunately, a structured approach to evaluating research evidence is possible and forms the basis of this talk. Adopting such an approach will allow you to provide better care and outcomes to your patients.

A case based presentation of things not to forget when managing critically ill patients. Each brief case presentation is paused at a critical diagnostic or management decision point to allow the audience to think. Then the important diagnostic or management point is revealed in the form of a commandment with explanation and supporting information that follows.

A discussion regarding the diagnosis, treatment, and outcomes of patients with autoimmune encephalitis. Particular emphasis will be placed on critically injured patients. 

Sepsis is certainly a major cause of mortality and morbidity worldwide, but how common is it? Do we have any idea of true incidence and mortality? This talk will critically examine current epidemiology and ask the questions as to how many deaths are directly attributable, and how many are avoidable.

Events occurring within the gastrointestinal tract are largely hidden from the clinician, yet they play an important role in the pathogenesis of critical illness.  This talk will trace the origins of the concept of the gut as the motor of critical illness from the time of the ancient Egyptians to the 21st century.

Provision of invasive mechanical ventilation is required for most critically ill patients admitted to an intensive care unit (ICU). Delivery of supplemental oxygen to ICU patients receiving mechanical ventilation often exposes them to a high fraction of inspired oxygen (FIO2) and higher than normal arterial oxygen partial pressure (PaO2). Humans are adapted to breathe air and it is plausible exposure to higher amounts of oxygen, either PaO2, FIO2, or both, might be harmful. Despite this, the optimal oxygen regimen in critically ill patients remains uncertain.  This talk will focus on existing evidence around oxygen therapy mechanically ventilated ICU patients and on the design of the Mega-ROX trial, 40000 patient RCT comparing conservative oxygen therapy and liberal oxygen therapy, which has recently begun enrolling patients.

Inflammation is the cornerstone of almost all life-threatening conditions motivating ICU admission. This lecture will try to give a picture of inflammatory response putting on scene the major actors of the play. Integrating their interactions, the sepsis will be used as an example to demonstrate the kinetic of inflammation and the potential to intervene with drugs to modulate the host response facing pathogens. The recent SARS-Cov-2 pandemic is a perfect example of the role of the host response to the virus as a key determinant of the clinical presentation, acquired specific immunity, and strategy for vaccine development.

In addition to the learning objectives below, additional concepts that will be covered include: Team training is a well-established approach for preventing errors in high-risk industries such as the military and the airline industry and is now being applied to the medical industry. Simulation is a promising new strategy for improving patient safety. Similar to flight simulators used by the airline industry, health care simulators allow providers to learn a procedure or protocol using high-tech mannequins instead of living patients. Pay-for-performance is a new approach for driving improvement in medical care by using financial incentives to reward hospitals that perform well on preestablished safety and quality measures. Those who want to lead in patient safety should innovate new approaches for preventing errors and study these approaches using rigorous research methodology.

The optimal treatment of vulnerable, critically ill patients depends primarily on two factors: the patient's innate response to the insult (host response) and minimising secondary insults (iatrogenesis). The host response is primarily genetically determined, but the adequacy of this response is influenced by associated co-morbidities and environmental factors such as access to effective health care. In this context, the greatest impact on human survival has evolved from advances in preventive medicine, public health initiatives, universal health access, and medical technology. While Intensive Care Medicine has resulted in major improvements in the care of critically ill patients, many of the fundamental interventions have evolved through physiologically-based paradigms, often predicated on normalising short-term variables, clinical measurements, or surrogate clinical endpoints. When many of these strategies are tested in comparative effectiveness studies, evidence of adverse impacts on patient-centered outcomes has emerged that is often attributed to iatrogenic injury. While some technological advances have delivered substantial benefits, the safety and efficacy of these technologies have not been evaluated by high-quality studies. This technological imperative is associated with inexorable indication creep, overuse, and misapplication of related strategies that are applied with little consideration of adverse down-stream consequences that independently affect patient-centered outcomes. Coupled with non-validated management bundles and clinical practice guidelines, the art and science of medicine is lost, so that effective treatment directed at augmenting the innate host response over the course and trajectory of critical illness becomes obscured.

This energetic talk starts with discussing the importance of Human Factors in Acute Care Medicine, and then pivots to how these ideas can be applied to understanding burnout, resilience, coping, and practical aspects of culture change in medicine. These ideas are all presented within the context of the COVID pandemic.