Podcasts about esicm

Dr. Markus Klimek and Dr. Joana Berger-Estilita join TopMedTalk at Euroanaesthesia 2024 to discuss education in anaesthesiology, including the latest ESICM perioperative intensive care e-course. Hosted by Desiree Chappell and Kate Leslie, this episode explores new methods of training and widening access to critical knowledge in anaesthesiology and intensive care.

Send us a Text Message (please include your email so we can respond!)Episode 50! In this episode we talk about SBT frequency and "Frequency of Screening and Spontaneous Breathing Trial Techniques" by Burns et al from JAMA 2024 that was released with the ESICM conference. In our second segment, instead of another trial we talk a little bit about the IV fluid shortage happening in the United States.FAST (JAMA): https://jamanetwork.com/journals/jama/fullarticle/2824928FAST (pubmed): https://pubmed.ncbi.nlm.nih.gov/39382222/If you enjoy the show be sure to like and subscribe, leave that 5 star review! Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!

Transfusion strategy for patients with acute brain injury, telehealth care, acute kidney injury after cardiac surgery, and weaning ventilatory support are the topics of 4 trials published in JAMA and presented at the 2024 European Society of Intensive Care Medicine meeting. JAMA Associate Editor Christopher Seymour, MD, MSc, joins Editor in Chief Kirsten Bibbins-Domingo, PhD, MD, MAS, to discuss. Related Content: Shifting Balance of the Risk-Benefit of Restrictive Transfusion Strategies in Neurocritically Ill Patients—Is Less Still More? Evaluating Complex Technological Innovations in Critical Care—Current Challenges and Future Directions Impact of Adsorptive Blood Purification on Kidney Outcomes Ventilator Weaning Strategies—Managing Interaction Between Randomized Treatments Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury Effect of Tele-ICU on Clinical Outcomes of Critically Ill Patients Extracorporeal Blood Purification and Acute Kidney Injury in Cardiac Surgery Frequency of Screening and Spontaneous Breathing Trial Techniques

Disturbances in neurological function due to primary neurological disorders or organ failure from critical illness are common in patients admitted to the ICU. In this episode, Dr. Zanotti discusses the neurological physical exam in the ICU. He is joined by Dr. Adam Rizvi, a neurologist with Neurocritical care and vascular neurology fellowship training who currently practices critical care, neurocritical care, and tele-neurology/tele-stroke in several hospitals in California. In addition to his clinical work, Dr. Rizvi is an accomplished educator and researcher. Additional Resources: Neurological examination of critically ill patients: a pragmatic approach: Report of an ESICM expert panel. Intensive Care Med 2014. https://pubmed.ncbi.nlm.nih.gov/24522878/ Critical Matters Podcast episode: Brain Death / Death by Neurological Criteria. Host: S. Zanotti. Guest: D. Greer: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1677810255 Clinical Neuroanatomy Made Ridiculously Simple. Edition 6. Stephan Goldberg, MD: https://amzn.to/4cC34uZ Books mention in the episode: Meditations. By Marcus Aurelius. Translation by Gregory Hayes: https://amzn.to/4eBxK1d

In neurocritical care, the initial evaluation is often fast paced, and assessment and management go hand in hand. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions. In this episode, Aaron Berkowitz, MD, PhD FAAN, speaks with Sarah Wahlster, MD, an author of the article “The Neurocritical Care Examination and Workup,” in the Continuum June 2024 Neurocritical Care issue. Dr. Berkowitz is a Continuum® Audio interviewer and professor of neurology at the University of California San Francisco, Department of Neurology and a neurohospitalist, general neurologist, and a clinician educator at the San Francisco VA Medical Center and San Francisco General Hospital in San Francisco, California. Dr. Wahlster is an associate professor of neurology in the departments of neurology, neurological surgery, and anesthesiology and pain medicine at Harborview Medical Center, University of Washington in Seattle, Washington. Additional Resources Read the article: The Neurocritical Care Examination and Workup Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @AaronLBerkowitz Guest: @SWahlster Full Episode Transcript Sarah Wahlster, MD   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by clicking on the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes. AAN members: stay tuned after the episode to hear how you can get CME for listening.  Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Sarah Wahlster about her article on examination and workup of the neurocritical care patient, which is part of the June 2024 Continuum issue on neurocritical care. Welcome to the podcast, Dr Wahlster. Can you please introduce yourself to the audience? Dr Wahlster: Thank you very much, Aaron. I'm Sarah Wahlster. I'm a neurologist and neurontensivist at Harborview Medical Center at the University of Washington. Dr Berkowitz: Well, Sarah and I know each other for many, many years. Sarah was my senior resident at Mass General and Brigham and Women's Hospital. Actually, Sarah was at my interview dinner for that program, and I remember meeting her and thinking, “If such brilliant, kind, talented people are in this program, I should try to see if I can find my way here so I can learn from them.” So, I learned a lot from Sarah as a resident, I learned a lot from this article, and excited for all of us to learn from Sarah, today, talking about this important topic. So, to start off, let's take a common scenario that we see often. We're called to the emergency room because a patient is found down, unresponsive, and neurology is called to see the patient. So, what's running through your mind? And then, walk us through your approach as you're getting to the bedside and as you're at the bedside. Dr Wahlster: Yeah, absolutely. This was a fun topic to write about because I think this initial kind of mystery of a patient and the initial approach is something that is one of the puzzles in neurology. And I think, especially if you're thinking about an emergency, the tricky part is that the evaluation and management go hand in hand. The thinking I've adapted as a neurointensivist is really thinking about “column A” (what is likely?) and “column B” (what are must-not-miss things?). It's actually something I learned from Steve Greenberg, who was a mutual mentor of us - but he always talked me through that. There's always things at the back of your head that you just want to rule out. I do think you evaluate the patient having in mind, “What are time-sensitive, critical interventions that this patient might need?” And so, I think that is usually my approach. Those things are usually anything with elevated intracranial pressure: Is the patient at risk of herniating imminently and would need a neurosurgical intervention, such as an EVD or decompression? Is there a neurovascular emergency, such as an acute ischemic stroke, a large-vessel occlusion, a subarachnoid hemorrhage that needs emergent intervention? And then other things you think about are seizures, convulsive/nonconvulsive status, CNS infection, spinal cord compression. But I think, just thinking about these pathologies somewhere and then really approaching the patient by just, very quickly, trying to gather as much possible information through a combination of exam and history. Dr Berkowitz: Great. So, you're thinking about all these not-to-miss diagnoses that would be life-threatening for the patient and you're getting to the bedside. So, how do you approach the exam? Often, this is a different scenario than usual, where the patient's not going to be able to give us a history or maybe necessarily even participate in the exam, and yet, as you said, the stakes are high to determine if there are neurologic conditions playing into this patient's status. So, how do you approach a patient at the bedside? Dr Wahlster: So, I think first step in an ICU setting (especially if the patient has a breathing tube) is you think about any confounders (especially sedation or metabolic confounders) - you want to remove as soon as possible, if able. I think as you do the exam, you try to kind of incorporate snippets of the history and really try to see - you know, localize the problem. And also kind of see, you know, what is the time course of the deterioration, what is the time course of the presentation. And that is something I actually learned from you. I know you've always had this framework of “what is it, where is it?” But I think in terms of just a clinical exam, I would look at localizing signs. I think, in the absence of being able to do the full head-to-toe neuro exam and interact with the patient, you really try to look at the brainstem findings. I always look at the eyes right away and look at, I think, just things like, you know, the gaze (how is it aligned? is there deviation? is there a skew? what do the pupils look like? [pupillary reactivity]). I think that's usually often a first step - that I just look at the patient's eyes. I think other objective findings, such as brainstem reflexes and motor responses, are also helpful. And then you just look whether there's any kind of focality in terms of - you know, is there any difference in size? But I think those are kind of the imminent things I look at quickly. Dr Berkowitz: Fantastic. Most of the time, this evaluation is happening kind of en route to the CT scanner or maybe a CT has already happened. So, let's say you're seeing a patient who's found down, the CT has either happened or you asked for it to happen somewhat quickly after you've done your exam, and let's say it's not particularly revealing early on. What are the sort things on your exam that would then push you to think about an MRI, a lumbar puncture, an EEG? You and I both spend time in large community hospitals, right, where “found down” is one of the most common chief concerns. In many cases, there isn't something to see on the CT or something obvious in the initial labs, and the question always comes up, “Who gets an MRI? Who gets an LP? Who gets an EEG?” - and I'm not sure I have a great framework for this. Obviously, you see focality on your exam, you know you need to look further. But, any factors in the history or exam that, even with a normal CT, raise your suspicion that you need to go further? Dr Wahlster: It's always a challenge, especially at a community hospital, because some of these patients come in at 1 AM where the EEG is not imminently available. But I think - let's say the CT scan is absolutely normal and doesn't give me a cause, but as an acute concerning deterioration, I think both EEG and LP would cross my mind. MRI I kind of see a little bit as a second-day test. I think there's very rare situation where an acute MRI would inform my imminent management. It's very informative, right, because you can see very small-vessel strokes. We had this patient that actually had this really bad vasculitis and we were able to see the small strokes everywhere on the MRI the day later, or sometimes helps you visualize acute brainstem pathology. But I think, even that - if you rule out a large-vessel occlusion on your CTA, there's brainstem pathology that is not imminently visible on the CT - it's nothing you need to go after. So, I do think the CT is a critical part of that initial eval, and whereas I always admire the neurological subspecialties, such as movements, where you just – like, your exam is everything. I think, to determine these acute time-sensitive interventions, the CT is key. And also, seeing a normal CT makes me a little less worried. You always look at these “four H” (they're big hypodensity, hyperdensity, any shift; is there hydrocephalus or herniation). I think if I don't have an explanation, my mind would imminently jump to seizure or CNS infection, or sometimes both. And I think then I would really kind of - to guide those decisions and whether I want to call in the EEG tech at 2 AM - I would, you know, again, look at the history and exam, see if there's any gaze deviation, tongue biting, incontinence - anything leading up towards seizure. I think, though, even if I didn't have any of those, those would strengthen my suspicion. If I really, absolutely don't have an explanation and the patient off sedation is just absolutely altered, I would still advocate for an EEG and maybe, in the meantime, do a small treatment trial. And I think with CNS infection - obviously, there are patients that are high risk for it - I would try to go back and get history about prodromes and, you know, look at things like the white count, fevers, and all of that. But again, I think if there's such a profound alteration in neurologic exam, there's nothing in the CT, and there's no other explanation, I would tend to do these things up front because, again, you don't want to miss them. Dr Berkowitz: Yeah, perfect. So many pearls in there, but one I just want to highlight because I'm not sure I've heard the mnemonic - can you tell us the four Hs again of sort of neurologic emergencies on CT? Dr Wahlster: Yeah. So, it's funny; for ages - I'm actually not sure where that's coming from, and I learned it from one of my fellows, one of our neurocritical care fellows - he's a fantastic teacher and he would teach our EM and anesthesia residents about it and his approach to CT. But yeah, the four H - he was always kind of like, “Look at the CT. Do you see any acute hypodensities, any hyperdensities?” And hypodensities would be involving infarct or edema; hyperdensities would be, most likely, hemorrhage (sometimes calcification or other things). Then, “Do you see hydrocephalus?” (because that needs an intervention). And, “Look at the midline structures and the ventricles.” And then, “Do you see any signs of herniation?” And he would go through the different types of herniation. But I thought that's a very good framework for looking at the “noncon” and just identifying critical pathology that needs some intervention. Dr Berkowitz: Yeah – so, hypodensity, hyperdensity, herniation, hydrocephalus. That's a good one – the four Hs; fantastic. Okay. So, a point that comes up a few times in your article - which I thought was very helpful to walk through and I'd love to pick your brain about a little bit – is, which patients need to be intubated for a neurologic indication? So, often we do consultations in medical, surgical ICUs; patients are intubated for medical respiratory reasons, but sometimes patients are intubated for neurologic reasons. So, can you walk us through your thinking on how to decide who needs to be intubated for the concern of depressed level of consciousness? Dr. Wahlster: It's an excellent question, and I think I would bet there's a lot of variation in practice and difference in opinion. There was actually the 2020 ESICM guidelines kind of commented on it, and those are great guidelines in terms of just intubation, mechanical ventilation of patients, and just acknowledging how there is a lack of really strong evidence. I would say the typical mantra (“GCS 8, intubate”) has been proposed in the trauma literature. And at some point, I actually dug into this to look behind the evidence, and there's actually not as much evidence as it's been put forth in guidelines and that kind of surprised me - that was just recently. I was like, “Actually, let me look this up.” I would say I didn't find a ton of strong evidence for it. I would say, as neurologist – you know, I'm amazed because GCS, I think is a - in some ways, a good tool to track things because it's so widely used across the board. But I would say, as neurologists, we all know that it sometimes doesn't account for some sort of nuances; you know, if a patient is aphasic, if a patient has an eyelid-opening apraxia - it can always be a little confounded. I'm amazed that GCS is still so widely used, to be frank. But I would say there is some literature - some school of thought - that maybe just blindly going by that mantra could be harmful or could not be ideal. I would say – I mean, I look at the two kind of functional things: oxygenation and ventilation. I think, in a neuro patient, you always think about airway protection or the decreased level of consciousness being a major issue (What is truly airway protection? Probably a mix of things). Then there's the issue of respiratory centers and respiratory drive - I think those are two issues you think about. But ultimately, if it leads to insufficient oxygenation - hypoxia early on is bad and that's been shown in several neurologic acute brain injuries. I think you also want to think about ventilation, especially if the mental status is poor to the point that the PCO2 elevates, that could also augment an ICP or exacerbate an ICP crisis. Or sometimes, I think there's just dysregulation of ventilation and there's hyperventilation to the point that the PCO2 is so low that I worry about cerebral vasoconstriction. So, I worry about these markers. I think, the oxygenation, I usually just kind of initially track on the sats. Sometimes, if the patient is profoundly altered, I do look at an arterial blood gas. And then there are things like breathing sounds (stridor, stertor [the work of breathing]). And I think something that also makes me have a lower threshold to intubate is if I'm worried and I want to scan, and I'm worried that the patient can't tolerate it - I want an imminent scan to just see why the patient is altered, or seizing, or presenting a certain way. Dr Berkowitz: All great pearls for how to think through this. Yeah - it's hard to think of hard and fast rules, and you can get to eight on the GCS in many different ways, as you said, some of which may not involve the respiratory mechanics at all. So, that's a helpful way of thinking about it that involves both the mental state, kind of the tracheal apparatus and how it's being managed by the neurologic system, and also the oxygen and carbon dioxide (sort of, respiratory parameters) – so, linking all those together; that's very helpful. And, related question – so, that's sort of for that patient with central nervous system pathology, who we're thinking about whether they need to be intubated for a primary neurologic indication. What about from the acute neuromuscular perspective (so, patients with Guillain-Barré syndrome or myasthenic crisis); how do you think about when to intubate those patients? Dr Wahlster: Yeah, absolutely - I think that's a really important one. And I think especially in a patient that is rapidly progressing, you always kind of think about that, and you want them in a supervised setting, either the ER or the ICU. I mean, there's some scores - I think there's the EGRIS score; there's some kind of models that predict it. I would say, the factors within that model, and based on my experience, often the pace of progression of reflex motor syndrome. I often see things like, kind of, changes in voice. You know, myasthenia, you look at things like head extension, flexion - those are the kind of factors. I would say there's this “20/30/40 rule” about various measures of, like, NIF and vital capacities, which is great. I would say in practice, I sometimes see that sometimes the participation in how the NIF is obtained is a little bit funky, so I wouldn't always blindly go by these numbers but sometimes it's helpful to track them. If you get a reliable kind of sixty and suddenly it drops to twenty, that makes me very concerned. But I would say, in general, it's really a little bit the work of breathing - looking at how the patient looks like. There's also (at some point) ABG abnormalities, but we always say, once those happen, you're kind of later in the game, so you should really - I think anyone that is in respiratory distress, you should think about it and have a low threshold to do it, and, at a minimum, monitor very closely. Dr Berkowitz: Yeah, we have those numbers, but so often, our patients who are weak, from a neuromuscular perspective, often have facial and other bulbar weakness and can't make a seal on the device that is used to check these numbers, and it can look very concerning when the patient may not, or can be a little bit difficult to interpret. So, I appreciate you giving us sort of the protocol and then the pearls of the caveats of how to interpret them and going sort of back to basics. So, just looking at the patient at the bedside and how hard they are working to breathe, or how difficult it is for them to clear their secretions from bulbar weakness. Moving on to another topic, you have a really wonderful section in your article on detecting clinical deterioration in patients in the neuro ICU. Many patients in the neuro ICU - for example, due to head trauma or large ischemic stroke or intracerebral hemorrhage, subarachnoid hemorrhage, or status epilepticus - they can't communicate with us to tell us something is getting worse, and they can't (in many cases) participate in the examination. They may be intubated, as you said, sedated or maybe even not sedated, and there's not necessarily much to follow on the exam to begin with if the GCS is very low. So, I'd love to hear your thoughts and your pearls, as someone who rounds in the neuro-ICU almost every day. What are you looking for at the bedside to try to detect sort of covert deterioration, if you will, in patients who already have major neurologic deficits, major neurologic injury or disease that we're aware of? I'm trying to see if there is some type of difference at the bedside that would lead you to be concerned for some underlying change and go back to the scanner or repeat EEG, LP, et cetera. Dr Wahlster: Yeah. I think that's an excellent question because that's a lot of what we do in the neuro ICU, right? And when you read your Clans, your residency, like, “Ah, QNR neuro checks, [IG1]  ” right? We often do that in many patients. But I think in the right patient, it can really be life or death a matter, and it is the exam that really then drives a whole cascade of changes in management and detects the need for lifesaving procedure. I would say it depends very much on the process and what you anticipate, right? If you have, for example, someone with a large ischemic stroke, large MCA stroke, especially, right, then there's sometimes conversations about doing a surgical procedure before they herniate. But let's say, kind of watch them and are worried that they will, you do worry about uncal herniation, and you pay attention to the pupil, because often, if the inferior division is infarcted, you know, you can see that kind of temporal tickling the uncus already. And so, I think those are patients that I torture with those NPi checks and checking the pupil very vigilantly. I would say, if it's a cerebellar stroke, for example, right, then you think about, you know, hydrocephalus. And often patients with cerebellar stroke - you know, the beauty of it is that if you detect it early, those patients can do so well, but they can die, and will die if they develop hydrocephalus start swelling. But I think, often something I always like to teach trainees is looking at the eye movements in upgaze and downgaze because, often, as the aqueduct, the third ventricle gets compressed and there's pressure on the colliculi – you kind of see vertical gaze get worse. But I would say I think it's always good to know what the process is and then what deterioration would look like. For example, in subarachnoid hemorrhage, where you talk about vasospasm - it's funny - I think a really good, experienced nurse is actually the best tool in this, but they will sometimes come to you and say, “I see this flavor,” and it's actually a constellation of symptoms, especially in the anterior ACA (ACom) aneurysms. You sometimes see patients suddenly, like, making funky jokes or saying really weird things. And then you see that in combination with, sometimes, a sodium drop, a little bit of subfebrile temperature; blood pressure shoot up sometimes, and that is a way the brain is sometimes regulating. But it's often a constellation of things, and I think it depends a little on the process that you're worried about. Dr Berkowitz: Yeah, that's very helpful. You just gave us some pearls for detecting deterioration related to vasospasm and subarachnoid hemorrhage; some pearls for detecting malignant edema in an MCA stroke or fourth ventricular compression in a large cerebellar stroke. Patients I find often very challenging to get a sense of what's going on and often get scanned over and over and back on EEG, not necessarily find something: patients with large intracerebral hemorrhage (particularly, in my experience, if the thalamus is involved) just can fluctuate a lot, and it's not clear to me actually what the fluctuation is. But you're looking for whether they're developing hydrocephalus from third ventricular compression with a thalamic hemorrhage (probably shouldn't be seizing from the thalamus, but if it's a large hemorrhage and cortical networks are disrupted and it's beyond sort of the subcortical gray matter, or has the hemorrhage expanded or ruptured it into the ventricular system?) And yet, you scan these patients over and over, sometimes, and just see it's the same thalamic hemorrhage and there's some, probably, just fluctuation level of arousal from the thalamic lesion. How do you, as someone who sees a lot of these patients, decide which patients with intracerebral hemorrhage - what are you looking for as far as deterioration? How do you decide who to keep scanning when you're seeing the same fluctuations? I find it so challenging - I'm curious to hear your perspective. Dr Wahlster: Yeah, no - that is a very tricky one. I mean, unfortunately, in patients with deeper hemorrhages or deeper lesions - you know, thalamic or then affecting brainstem - I think those are the ones that ultimately don't have good, consistent airway protection and do end up needing a trach, just because there's so much fluctuation. But I agree - it's so tricky, and I don't think I can give a perfect answer. I would say, a little bit I lean on the imaging. And for example - let's say there's a thalamic hemorrhage. We recently actually had a patient - I was on service last week - we had a thalamic hemorrhage with a fair amount of edema on it that was also kind of pressing on the aqueduct and didn't have a lot of IVH, right? But it was, like, from the outside pushing on it and where we ended up getting more scans. And I have to say, that patient actually just did fine and actually got the drain out and didn't need a shunt or anything, and actually never drained. We put an EVD and actually drained very little. So, I think we're still bad at gauging those. But I think, in general, my index of suspicion or threshold to scan would be lower if there was something, like, you know, a lot of IVH associated, if, you know, just kind of push on the aqueduct. It's very hard to say, I think. Sometimes, as you get to know your patients, you can get a little bit of a flavor of what is within normal fluctuation. I think it's probably true for every patient, right? - that there's always some fluctuation within the realm of like, “that's what he does,” and then there's something more profound. Yeah, sorry - I wish I could give a better answer, but I would say it's very tricky and requires experience and, ideally, you really taking the time to examine the patient yourself (ideally, several times). Sometimes, we see the patient - we get really worried. Or the typical thing we see the ICU is that the neurosurgeons walk around at 5 AM and say, like, “She's altered, she's different, she's changed.” And then the nurse will tell you at 8 AM, like, “No, they woke up and they ate their breakfast.” So, I think really working with your nurse and examining the patient yourself and just getting a flavor for what the realm of fluctuation is. Dr Berkowitz: Yeah - that's helpful to hear how challenging it is, even for a neurocritical care expert. I'm often taking care of these patients when they come out of the ICU and I'm thinking, “Am I scanning these patients too much?” Because I just don't sort of see the initial stage, and then, you know, you realize, “If I'm concerned and this is not fitting, then I should get a CT scan,” and sometimes you can't sort it out of the bedside. So, far from apologizing for your answer, it's reassuring, right, that sometimes you really can't tell at the bedside, as much as we value our exam. And the stakes are quite high if this patient's developed intraventricular hemorrhage or hydrocephalus, and these would change the management. Sometimes you have these patients the first few days in the ICU (for us, when they come out of the ICU) are getting scanned more often than you would like to. But then you get a sense of, “Oh, yeah - these times of day, they're hard to arouse,” or, “They're hard to arouse, but they are arousable this way,” and then, “When they are aroused, this is what they can do, and that's kind of what we saw yesterday.” And yet, as you said, if anyone on the team (the resident, the nurse, the student, our neurosurgery colleague) says, “I don't think this is how they were yesterday,” then, very low threshold to just go back and get a CT and make sure we're not missing something. Dr. Wahlster: Exactly. Yeah. I would say the other thing is also certain time intervals, right? If I'm seeing a patient that may be in vasospasm kind of around the days seven to ten, for the first fourteen day, I would be a little bit more nervous. Or with swelling - acute ischemic stroke says that could peak swelling, when knowing which [IG2]  , I would just be more anxious or have a lower threshold to scan. Yeah. Dr Berkowitz: Yeah - very helpful. Well, thank you so much for joining me today on Continuum Audio. Dr Wahlster: Thank you very much, Aaron. Dr Berkowitz: Again, today we've been interviewing Dr Sarah Wahlster, whose article, “Examination and Workup of the Neurocritical Care Patient” appears in the most recent issue of Continuum, on neurocritical care. Be sure to check out Continuum Audio episodes from this and other issues. And thank you so much to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. And right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024 or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

Episode 29! We stray a little bit from our new and old article structure to talk about two recently published but slightly different ARDS recommendations from ATS and ESCIM. We compare and contrast them and give our takes on the data and evidence.Thanks to everyone who emails in and gives feedback, we will do our mail bag next episode!ATS Guidelines: https://pubmed.ncbi.nlm.nih.gov/38032683/ESICM guidelines: https://pubmed.ncbi.nlm.nih.gov/37326646/Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!

Acute respiratory distress syndrome (ARDS) is the term applied to a spectrum of conditions with different etiologies that share common clinical-pathological characteristics including: increased permeability of the alveolo-capillary membrane, resulting in inflammatory edema; increased non-aerated lung tissue resulting in higher lung elastance (lower compliance); and increased venous admixture and dead space, which result in hypoxemia and hypercapnia. The new updated ESICM guidelines have been published highlighting a new approach to ARDS in terms of definitions, phenotyping, and respiratory support strategies. To discuss ARDS from the new guidelines to bedside applied physiology we have interviewed Professor Gattinioni and invite you to follow the conversation in the following podcast.

Episode 24! Three trials about COVID were published with ESICM which we talk about all three here. COVID has been decreasing in prevalence in our ICU at least so we anchor our discussion around what we can learn from these trials about ARDS in general or what we can carry forward to future pandemics compared to our typical "Are we using this in our practice".Simvastatin: https://pubmed.ncbi.nlm.nih.gov/37888913/Vitamin C: https://pubmed.ncbi.nlm.nih.gov/37877585/Convalescent Plasma: https://pubmed.ncbi.nlm.nih.gov/37889107/Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!

Episode 23! We spend a little bit of time talking about our recent conference related travel and food experience but dive into our coverage of the trials that released with ESICM including "Inhaled Amikacin to Prevent Ventilator-Associated Pneumonia" by Ehrmann et al published in NEJM and "Landiolol and Organ Failure in Patients With Septic Shock" by Whitehouse et al in JAMA, both October 2023AMIKINHAL: https://pubmed.ncbi.nlm.nih.gov/37888914/STRESS-L: https://pubmed.ncbi.nlm.nih.gov/37877587/Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!

Entre os dias 21 e 25 de outubro aconteceu em Milão, na Itália, o European Society of Intensive Care Medicine – ESICM 2023, congresso que abordou diversos temas sobre a área da medicina intensiva com os maiores especialistas do mundo. Neste episódio, Yuri Albuquerque, intensivista e conteudista do Portal, reúne as principais discussões sobre medicina intensiva abordadas no evento, que deu ênfase à monitorização hemodinâmica, à ventilação mecânica e à sepse. Confira agora dando o play! Confira esse e outros posts no Portal PEBMED e siga nossas redes sociais! Facebook Instagram Linkedin Twitter

Transportation of critically ill patients is inevitable in most health systems. Prehospital transportation (PHT) may be necessary after a major injury or as a result of a life-threatening illness – for example, myocardial infarction, intracranial haemorrhage, or metabolic coma. On our ESICM Academy, we offer a course series on Patient Transportation, from the general introduction to conducting interfacility and intrahospital patient transportation and prehospital transport in Critical Care. Hear more from one of the authors in this podcast. The ESICM Academy is accredited by the European Accreditation Council for Continuing Medical Education (EACCME) and offers updated, peer-reviewed, evidence-based training material, free of charge for ESICM members. Speaker:Michael J LAURIA. Former Pararescueman in the US Air Force and Critical Care/Flight Paramedic. Currently Emergency Medicine Physician, University of New Mexico Health Sciences Center; EMS/Critical Care Fellow, Flight Physician; Associate Medical Director for Lifeguard Air Emergency Services (US).

Central nervous system (CNS) infections significantly burden ICU physicians' daily clinical work. Diagnosis can be challenging, and timely management is of the utmost importance. Meningoencephalitis is one of the CNS infections for which the epidemiological studies conducted in adult patients suggest that approximately one in two will require care in an intensive care unit. In those patients requiring ICU admission, meningoencephalitis is associated with a poor prognosis, including refractory seizures, prolonged hospital stay, neurological disability, and death. The EURECA study endorsed by the ESICM intended to characterise the clinical presentation, etiologies, and outcomes in adult patients with severe meningoencephalitis requiring care in the ICU. We discuss its findings in this episode. Help us review our educational podcasts! Complete this short survey here. Speakers:Romain SONNEVILLE. Bichat Claude Bernard University Hospital, APHP, Université Paris Cité (FR). Laura GALARZA. Laura Galarza Hospital Universitari General de Castellón (ES). Chair, ESICM NEXT Committee.

ARDS Part II Special Guest: Steven Lemieux, PharmD, BCPS, BCCCP 03:45 – ESICM guidelines and ARDS definition 11:50 – Phenotypes and respiratory support 23:50 – Corticosteroids 34:40 – NMBA, pulmonary vasodilators, and VV ECMO 44:00 - Fun facts and take-home points Reference List: https://pharmacytodose.files.wordpress.com/2023/08/ards-part-ii-references.pdf PharmacyToDose.Com  @PharmacyToDose  PharmacyToDose@Gmail.com Learn more about your ad choices. Visit megaphone.fm/adchoices

Coagulopathy is a severe and frequent complication in critically ill patients, for which the pathogenesis and presentation may be variable depending on the underlying disease. Therefore, a review has been conducted to differentiate between hemorrhagic coagulopathies, characterised by a hypercoagulable and hyperfibrinolysis state, and thrombotic coagulopathies with a systemic prothrombotic and antifibrinolytic phenotype, based on the dominant clinical phenotype. Dr Julie Helms, our podcast guest, will explain more about the review and discuss the differences in pathogenesis and treatment of the common coagulopathies. Original paper: How to manage coagulopathies in critically ill patients SpeakersJulie HELMS. Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg (FR). Ahmed ZAHER. Oxford University Hospitals (UK). NEXT Committee member, ESICM.

End-of-life care is an approach to a terminally ill patient that shifts the focus of care to symptom control, comfort, dignity, quality of life, and quality of dying rather than treatments aimed at cure or prolongation of life. A detailed description of the concept of the end of life care and as well how to deal with end-of-life situations are discussed in the podcast. SpeakersJulie BENBENISHTY. Hadassah Hebrew University Medical Center, Jerusalem (IL). Head of the European critical care doctoral educated nurses group. Ahmed ZAHER. Oxford University Hospitals (UK). NEXT Committee member, ESICM.

The Surviving Sepsis Campaign (SSC) produces and regularly updates guidelines for managing patients with sepsis and septic shock. However, deviation from guidelines is frequently observed in the intensive care unit. The last iteration of the SSC includes 79 recommendations where the impact on mortality remains unclear for some of them. Prioritising the recommendations based on their relative impact on mortality would be helpful to the clinician. A recent study has been carried out to identify among all SSC recommendations applicable during the first 24 h following sepsis onset, a subset of guidelines that should be prioritised to minimise 28-day all-cause mortality.Original paper: Machine-learning-derived sepsis bundle of careSpeakersRomain PIRRACCHIO. Department of Anesthesia and Perioperative Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco (US). Ana-Maria IOAN. Fundacion Jimenez Diaz University Hospital, Madrid (ES). Spain. NEXT Committe member, ESICM.

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. In this context, biomarkers could be considered indicators of either infection or dysregulated host response or response to treatment and/or aid clinicians in prognosticating patient risk.A recently published narrative review provides current data on the clinical utility of pathogen-specific and host-response biomarkers, offers guidance on optimising their use, and proposes the need for future research. In this podcast, Dr Povoa, one of the leaders of this review, details these findings. Original paper: How to use biomarkers of infection or sepsis at the bedside: guide to cliniciansSpeakersPedro PÓVOA. NOVA Medical School, New University of Lisbon (PT). Laura BORGSTEDT. Department of Anesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich (DE). NEXT Committe member, ESICM.

Individualising drug dosing using model-informed precision dosing (MIPD) of beta-lactam antibiotics and ciprofloxacin has been proposed as an alternative to standard dosing to optimise antibiotic efficacy in critically ill patients. However, randomised clinical trials (RCT) on clinical outcomes have been lacking.In this podcast, Drs Ewoldt and Abdulla relate how they conducted a multicentre RCT in 8 Dutch hospitals. It included patients admitted to the intensive care unit (ICU) treated with antibiotics and randomised to MIPD with dose and interval adjustments based on monitoring serum drug levels (therapeutic drug monitoring) combined with pharmacometrics modelling of beta-lactam antibiotics and ciprofloxacin. Original paper: Model‑informed precision dosing of beta‑lactam antibiotics and ciprofloxacin in critically ill patients: a multicentre randomised clinical trialSpeakersTim M. J. EWOLDT. Department Hospital Pharmacy, Erasmus University Medical Center, Rotterdam (NL).Alan ABDULLA. Department Hospital Pharmacy, Erasmus University Medical Center, Rotterdam (NL).Ana-Maria IOAN. Intensive Care Medicine Unit, Fundación "Jiménez Díaz" University Hospital, Madrid (ES). NEXT Committe member, ESICM.

In traumatic brain injury, the lung and the brain are caught in a complex interplay, where the challenges of managing one can affect the other. Chiara Robba is a consultant in Neuro and General Intensive Care at Policlinico San Martino, Genova.  She has a PhD in neuroscience and is the current chair of the NeuroICU section of the ESICM.  Chiara joins Todd to discuss her thoughts on this important issue.See omnystudio.com/listener for privacy information.

Neste episódio, Hiago Bastos, intensivista e colunista do Portal PEBMED, traz os principais destaques do European Society Of Intensive Medicine Congress (ESICM 2022). Clique e ouça o episódio!

The aim of the ERC-ESICM guidelines on temperature control after cardiac arrest in adults is to provide evidence-based guidance in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The invited experts of this podcast, Prof Sandroni and Prof Nolan, describe the methodology followed and explain the panel suggestions on guideline implementation and the identified priorities for future research. Listen to their interview! Original article: https://rdcu.be/cGdbg (ERC‑ESICM guidelines on temperature control after cardiac arrest in adults) Speakers Claudio SANDRONI. Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome (IT). Chair of the ESICM Trauma & Emergency Medicine Section. Jerry P. NOLAN. School of Clinical Science, University of Bristol, Bristol, UK and Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath (UK). Laura BORGSTEDT. Clinic for Anaesthesiology and Intensive Care Medicine and University of Munich (DE). ESICM NEXT Committee Member.

Neuromonitoring is considered a crucial and fundamental process to monitor patients in critical care settings. In this podcast, ESICM NEXT member Denise Battagliani interviews Chiara Robba on the ultimate findings regarding neuromonitoring, including: basics of neuromonitoring research; indications for neuromonitoring of patients who do (not) suffer any direct brain injury; the rationale in neuromonitoring patients with sepsis, COVID-19 and liver failure and the most appropriate tools to use for each of this cohort of patients; the use of neuromonitoring tools during the perioperative period for neurosurgical patients and patients who undergo cardiac and vascular surgeries. Speakers Chiara ROBBA. Consultant in Neuro and General Intensive Care, Policlinico San Martino Genoa, (IT). Chair-Elect of the Neuro Intensive Care section of the ESICM. Denise BATTAGLINI. Consultant in intensive care at San Martino Policlinico Hospital, Genoa, Italy (IT). ESICM NEXT Committee Member.

Given the rapidity with which critically ill patients with bleeding can deteriorate, having a standardised approach to transfusion in these patients can be of great assistance to clinicians working in time-pressured circumstances. An expertise task force created within ESICM has developed an https://doi.org/10.1007/s00134-021-06531-x (international guideline )that provides guidance for clinicians caring for critically ill patients with massive and non-massive bleeding. 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendations), and 11 PICO (population, intervention, comparison, and observation) with insufficient evidence to make recommendations were generated and published. To understand and clarify further this research, Dr Helms, ICM Associate Editor, has interviewed one of the leading experts of this study Dr A. Vlaar. Check out the following podcast to learn more. Speakers: Julie HELMS. Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (FR). Associate Editor of Intensive Care Medicine Alexander P.J. VLAAR. Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam (NL).

Ultrasonography is an evolving skill in critically ill patients. We provide a large number of statements regarding the required ultrasonographic basic skills for the management of critically ill patients. Original article: Speakers: https://rdcu.be/cClco (Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine) Chiara ROBBA. Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa (IT) and Department of Surgical Sciences and Integrated Diagnostics (DISC), Genoa (IT). Chair, ESICM Neuro Intensive Care Section. Adrian WONG. Department of Critical Care, King's College Hospital, London (UK). Chair, ESICM Social Media & Digital Content Committee. Antoine VIEILLARD-BARON. Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Billancourt, Boulogne (FR) and INSERM UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif (FR). ESICM Secretary. Laura GALARZA. Hospital General Universitario, Castellón (ES); Chair-Elect, ESICM NEXT Committee

For family members of survivors, the ICU diary is an important source of medical information, provides a way for them to register their presence at the patient's bedside and express their feelings, and contributes to humanizing the ICU staff. For relatives of non-survivors, the diary also works as a concrete memory of their loved one's last days before dying, helping relatives to cope with bereavement. Systematic Review: https://rdcu.be/cobOc (Exploring family members' and health care professionals' perceptions on ICU diaries: a systematic review and qualitative data synthesis.) Imaging in Intensive Care Medicine from the inside: https://rdcu.be/cobNO (Caring for COVID‑19 patients and their relatives with the ICU diary) Speakers: Dr Rahul COSTA-PINTO. Austin Hospital, Melbourne - Australia; ESICM NEXT Committee Member. Mr Johannes MELLINGHOFF. Critical Care Nurse & Senior Lecturer Kingston & St Georges University of London. Current Chair N&AHP Committee of the ESICM. Dr Bruna BRANDAO BARRETO. Intensive Care Unit, Hospital da Mulher, Salvador, Brazil.

Following on from the recent ESICM webinars on https://mediatheque.cyim.com/mediatheque/media.aspx?mediaId=100378&channel=71460 (haemodynamic monitoring) and https://mediatheque.cyim.com/mediatheque/media.aspx?mediaId=99776&channel=71460 (vasopressors), Dr Wong interviews Dr Rola on his thoughts on a range of issues, from the use of ultrasound, venous congestion to the Pulmonary Artery Catheter as well as his predictions for the direction of future research. Speakers: Dr Adrian WONG. Consultant in Intensive Care Medicine and Anaesthesia, King's College Hospital, London (UK) and current Chair of the ESICM Editorial and Publishing Committee (EPC). Dr Philippe ROLA. Chief of Service, Intensive Care Unit, Santa Cabrini Hospital, Montreal, Canada.

Ultrasound has become an indispensable tool while caring for critically ill patients. Increasing availability at bedside and the role that it plays in the diagnosis and management of patients had made that clinicians incorporate ultrasound as a part of their bedside clinical examination. Some colleagues argue that it can be a good hemodynamic tool too, however, others disagree. Speakers: Dr Laura GALARZA. Intensivist at the University General Hospital in Castellon, Spain and Deputy Chair of the ESICM NEXT committee. Prof Xavier MONNET. Professor of Intensive Care at the Paris-South University, working in the Medical Intensive Care Unit of the Bicêtre Hospital. Prof. Monnet's main fields of research are acute circulatory failure and its treatment, haemodynamic monitoring and heart-lung interactions. He is the Chair of the ESICM cardiovascular dynamics section. 

This piece focuses on intensive care, the use of data and the future of fluid therapy research and its related physiological outcomes. The article mentioned in this podcast is here: "Perioperative haemodynamic therapy for major gastrointestinal surgery: the effect of a Bayesian approach to interpreting the findings of a randomised controlled trial" https://bmjopen.bmj.com/content/9/3/e024256 Presented by Desiree Chappell and Monty Mythen with their guest Maurizio Cecconi, Head of the Anaesthesia and Intensive Care Department at Humanitas Research Hospital; President-elect of the European Society of Intensive Care Medicine (ESICM) for 2020-2021, Chair Division of Scientific Affairs at ESICM; Director of the Master in Patient Blood Management at Humanitas University. -- Like this, want more? Rupert Pearse, one of the co-authors of the above article, was interviewed on TopMedTalk here: https://www.topmedtalk.com/anaesthesia-2019-rupert-pearse/

This piece focuses on intensive care, the use of data and the future of fluid therapy research and its related physiological outcomes. The article mentioned in this podcast is here: "Perioperative haemodynamic therapy for major gastrointestinal surgery: the effect of a Bayesian approach to interpreting the findings of a randomised controlled trial" https://bmjopen.bmj.com/content/9/3/e024256 Presented by Desiree Chappell and Monty Mythen with their guest Maurizio Cecconi, Head of the Anaesthesia and Intensive Care Department at Humanitas Research Hospital; President-elect of the European Society of Intensive Care Medicine (ESICM) for 2020-2021, Chair Division of Scientific Affairs at ESICM; Director of the Master in Patient Blood Management at Humanitas University. -- Like this, want more? Rupert Pearse, one of the co-authors of the above article, was interviewed on TopMedTalk here: https://www.topmedtalk.com/anaesthesia-2019-rupert-pearse/

"You're a bit further down the line with managing these patients. Any particular advice?" Italy, the situation is difficult but there are now clear lessons to be learned as the first chapter in the front line battle against the consequences of a global pandemic is written. Hear how the story regarding treatment for this disease evolved in Italy and consequently around the world. Has the debate regarding acute respiratory distress syndrome (ARDS) been a red herring? What is the effectiveness of continuous positive airway pressure (CPAP) in these cases? Are all COVID 19 patients the same? Crucially - what can cardiac dysfunctions in these patients tell us? This podcast is essential listening for students and medical practitioners who want to hear a real life discussion about one of the most important medical and population health emergencies the world has ever faced. Presented by Joff Lacey with Monty Mythen and additional questions from Desiree Chappell alongside their guest, Maurizio Cecconi, Head of the Anaesthesia and Intensive Care Department at Humanitas Research Hospital; President-elect of the European Society of Intensive Care Medicine (ESICM) for 2020-2021, Chair Division of Scientific Affairs at ESICM; Director of the Master in Patient Blood Management at Humanitas University. Thank you to our sponsor Edwards Lifesciences. Edwards clinical education (ECE): https://www.edwards.com/clinicaleducation  

TopMedTalk is live from Euroanaesthesia 2019; recognised worldwide as one of the most important and influential annual congress in anaesthesiology. Over 6000 international delegates alongside more than 100 exhibitors from more than 80 countries, Euroanaesthesia is truly an outstanding international platform. Join Us at the conference in this series of special live podcasts. Presented by Desiree Chappell and Monty Mythen with their guest Maurizio Cecconi, Head of the Anaesthesia and Intensive Care Department at Humanitas Research Hospital; President-elect of the European Society of Intensive Care Medicine (ESICM) for 2020-2021, Chair Division of Scientific Affairs at ESICM; Director of the Master in Patient Blood Management at Humanitas University.

Le Professeur Jean Reignier, PUPH en médecine intensive réanimation au CHU de Nantes, nous parle des objectifs caloriques, du timing et de la voie d'administration de la nutrition en réanimation Articles en lien :ESPEN guideline on clinical nutrition in the intensive care unit, doi10.1016/j.clnu.2018.08.037 Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines, doi 10.1007/s00134-016-4665-0. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial, doi 10.1001/jama.2012.137. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults, doi 10.1056/NEJMoa1502826

Dr. Mike Brogan interviews Dr. Mauro Oddo on the most recent ESICM practice guidelines on general fluid resuscitation management, hyperosmolar therapies, and the use of fluids in treating delayed cerebral ischemia for neurointensive care patients. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Jim Siegler. Our production staff includes Joshua Levine, Becca Stickney, Michael Brogan, Starane Shepherd, Benjamin Miller, and Ramani Balu. Music by Lee Rosevere. Oddo M, Poole D, Helbok R, Meyfroidt G, Stocchetti N, Bouzat P, Cecconi M, Geeraerts T, Martin-Loeches I, Quintard H, Taccone FS, Geocadin RG, Hemphill C, Ichai C, Menon D, Payen JF, Perner A, Smith M, Suarez J, Videtta W, Zanier ER and Citerio G. Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations. Intensive care medicine. 2018;44:449-463.

In this week’s episode you’ll hear an invigorating conversation with Francesca Rubulotta. This power-packed, enthusiastic, passionate, water polo-playing, Italian doctor, now living and working in London, UK, is seriously ambitious to help patients other than those in her ICU, mostly by advancing education using technological innovation. Francesca is a Consultant and Honorary Senior Clinical Lecturer in Anaesthesia and Intensive Care Medicine at Imperial College Medical School. She studied medicine and anaesthesia in Italy and intensive care in Belgium, but also worked in the USA and the Netherlands on a journey that arrived in London 10 years ago. Francesca has been the Chair of the past division of professional development of the European Society of Intensive Care Medicine (ESICM) and is currently the Chair of the ESICM’s CoBaTrICE project. She leads and has led many other committees and organisations, and is presently the first ever female Presidential candidate in the ESICM general election (with the ballot open until June 11). Francesca has diverse clinical interests including end of life care, ethical aspects of intensive care, rapid response systems, and clinical research. She speaks 5 European languages, travels and speaks around the globe and has won masters world championships as a waterpolo player. In this conversation, Francesca demonstrates a deep understanding of, a strong passion for and substantial experience in running educational programs and courses in an innovative way using digital technology. She also tells of her desire to maximize the reach of education to less-developed areas of the world and her hope for more balance between the genders in intensive care. We also cover: The story of her multinational career so far How she obtained her current job in the United Kingdom How her intensive care career began by translating her intensivist father’s slides into English as a high school student How both she and her sister are now intensivists The benefits of training under some of the superstars of intensive care Her observation that the best intensivists keep it simple A story about how her change in demeanour helped her team understand how a clinical situation had turned serious The importance of empowering junior staff to make decisions Her fundamental desire to have daily physical contact with each patient How she took an ex-long-term ICU patient to the pub Raised expectations that educators should now deliver TED-like talks The honour of standing as an election candidate to be ESICM President The possibility of a global intensive care society one day Her passion for waterpolo and the vital importance of following our passions outside of medicine How yoga helps her look after her mind Learning from the mistakes she has made along the way And some thoughts about gender inequality in intensive care. My genuine hope with the Mastering Intensive Care podcast is to inspire and empower you to bring your best self to work and to adopt some of the habits and behaviours my guests give their perspectives on, with the ultimate purpose of improving outcomes for all of our patients. Please help me to spread the message by simply emailing your colleagues, posting on social media or subscribing, rating and reviewing the podcast. Feel free to leave a comment on the Facebook “mastering intensive care” page, on the LITFL episode page, on twitter using #masteringintensivecare, or by sending me an email at andrew@masteringintensivecare.com. Thanks for listening on the journey towards mastering intensive care. Andrew Davies   -------------------- Show notes (people, organisations, resources or links mentioned in the episode): Link to Francesca Rubulotta’s ESICM President campaign: https://mailchi.mp/b3364cf0ed73/francesca-rubulotta-esicm?utm_source=mailchimp&utm_campaign=030026c6e1f0&utm_medium=page Francesca Rubulotta’s logo, suggesting representation (globe), education (eye) and innovation (light): Twitter handle for Francesca Rubulotta: @frubulotta Mastering Intensive Care podcast: http://masteringintensivecare.libsyn.com Mastering Intensive Care at Life In The Fast lane: https://lifeinthefastlane.com/litfl/mastering-intensive-care Twitter handle for Andrew Davies: @andrewdavies66 Email Andrew Davies: andrew@masteringintensivecare.com

- Fuga dal Ps, a Varese chiedono il trasferimento in massa http://bit.ly/varese_trasferimento- Cecconi (M5S): “Vorrei una nuova alba per la professione” http://bit.ly/cecconi_intervista- Il risk management in Triage http://bit.ly/gft_corso- Studio mondiale sulle lesioni da pressione, l’appello alle TI http://bit.ly/decubicus- Infermieri italiani premiati sul palco dell’Esicm http://bit.ly/premio_esicm

Fluids in Critical Care: Time to SPLIT With Normal Saline? Summary by: Paul Young Intravenous fluid therapy is a ubiquitous treatment for critically ill patients and has been used in clinical practice for over 175 years. Despite this long history, the majority of intravenous fluids have not been subjected to the same level of scrutiny as other drugs. That said, large-scale fluid trials evaluating albumin and starch solutions compared to 0.9% saline have been conducted and their results have changed clinical practice around the world so that crystalloid fluid therapy is now predominant in many parts of the world. While 0.9% saline is the world’s most commonly prescribed crystalloid fluid, increasingly clinicians are turning to buffered or balanced crystalloid solutions as an alternative to 0.9% saline. This practice change from 0.9% saline towards balanced crystalloids is not based on high quality evidence but is supported by observational data suggesting that saline may be associated with an increased risk of renal toxicity and mortality compared to buffered crystalloids. This talk gives an overview of the data comparing the comparative effectiveness of 0.9% saline and buffered crystalloids, provides an overview of the historical context of intravenous fluid therapy (and proctoclysis), and describes the design of the Saline vs. Plasma-Lyte 148® for Intravenous fluid Therapy (SPLIT) trial which has now been completed and was recently published in the Journal of the American Medical Association. External Links• [The Bottom line] SPLIT trial reviewed• [article] Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial• [editorial] Editorial accompanying paper• [videocast] Presentation of SPLIT trial at ESICM by Dr Paul Young• [Further reading] Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults• [St Emlyn's] SPLIT trial published. Saline or Plasmalyte on the ICU?

Paul Young is the man of the moment. In one week has has published the SPLIT trial in JAMA, the HEAT trail in the NEJM and presented both at the ESICM conference. Platform Trials. In this interview Paul discusses The SPLIT Trial - the first trial to substantially look at buffered crystalloids vrs saline and now really paves the way for a definitive trial in this area. He answers some questions that have been asked such as was the volume of fluid sufficient to demonstrate an effect, why PlasmaLyte was used and what he’ll be doing following these results. HEAT is a much anticipated trial looking at the effect of early administration of acetaminophen to treat fever due to probable infection. This intervention did not affect the number of ICU-free days. Paul captured out imagination on this topic with a talk at SMACC in 2013 and now the dialogue really begins. We discuss where to go from here on this topic that often stimulates passionate debate… Finally we discuss Platform trials and how they will save the world. This was  topic of a talk Paul gave in Chicago which will be released soon. Read this fascinating paper by Berry Connor and Lewis for a real insight into the hot topic.

Welcome to a momentous occasion for MCCP. Today we have Dr. Rahul Nanchal, the co-Chair of both the SCCM and ESICM task force on hepatic failure in the ICU; making him one of the world’s foremost experts in the field of liver failure! Dr. Nanchal visits from the Medical College of ...

A summary of my experiences at the second and third days of the ESICM. Links include: Here is the IMPACT calculator for prognosticating in traumatic brain injury For the Brain Tissue Oxygen Monitoring in Traumatic Brain Injury (BOOST 2) go here For Simon Finfer's talk on the DECRA study click here  The Girault paper: Noninvasive Ventilation and Weaning in Patients with Chronic Hypercapnic Respiratory Failure For lung ultrasound, you should look at both the Bouhamed paper and the Sartori paper, both here in fulltext for free. There are a few lung ultrasound videos out there too, like this one The BLUE protocol is here Brain trauma foundation guidelines are here Free fulltext of ECASS III is here Martin Smith on intracerebral haemorrhage is all summarised here A good summary of treating refractory status epilepticus is here Some good neuro papers from the last year: Cerebral tissue oxygenation measured by two different probes: challenges and interpretation For the paper on measuring brain temperature with MRI spectroscopy, go here Ultrasound of the optic nerve sheath to estimate ICP is here Invasive and noninvasive assessment of cerebral oxygenation in patients with severe traumatic brain injury This is probably a more useful paper on the risk factors for delirium after cardiac surgery The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest Also see our presentation on this topic here Top haemodynamic papers: Here is an older paper on using IVC diameter for volume responsiveness, and here is the paper Alex Mebezza referred to Comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial Effects of fluids on microvascular perfusion in patients with severe sepsis Top Mechanical ventilation papers: Non-invasive ventilation in postoperative patients: a systematic review Comparison of patient–ventilator interfaces based on their computerized effective dead space Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU Post-traumatic stress disorder after weaning from prolonged mechanical ventilation Top ICU infection/micro papers from the last year: Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study Intrapleural use of tissue plasminogen activator and DNase in pleural infection Best of metabolic and sepsis articles last year: Impact of hypoxic hepatitis on mortality in the intensive care unit Assessing adrenal insufficiency of corticosteroid secretion using free versus total cortisol levels in critical illness On TEGs and ROTEM: Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy A Cochrane review is here

A description of some of the presentations I attended on the first day of this year's ESICM conference in Berlin. Here are links to some of the material discussed in this Podcast: For the WHO Malaria Guidelines, look here For an article on paroxysmal sympathetic hyperactivity, go here For more about VAP, there's this, and for prevention, look here. Here is the JAMA paper on hydrocortisone in multi-trauma patients For review on NAVA look here. Here is the key Subarachnoid Haemorrhage paper: Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference