emergency lectures - post resuscitation care

Post Resuscitation CareDr Ian Seppelt

Senior Specialist in Intensive Care Medicine, Nepean Hospital

Senior Research Fellow, George Institute for Global Health,

University of Sydney

(an introduction to basic intensive care medicine)

• 95% of intensive care medicine is “getting the basics right”

• The other 5% is picking up the ….

The other 5% is picking up the ….

Post Resuscitation Care

1. General care– Fluid Management– Pain, sedation, delirium– Nutrition– Blood sugar control

2. Post cardiac arrest– Therapeutic hypothermia– Prognosis after cardiac arrest

Where are we heading with intensive care research?

There are no magic bullets• It is implausible that any treatment will reduce

mortality by 14%• The attributable mortality of sepsis is about 10%

[Bellomo, ANZICS APD, 2010]

• We can realistically expect an effect size of 1-2%

• What costs < $2,500/patient in ICU– Better fluid therapy or fluid balance management,– Better transfusion practices, – Better nutrition, – Better sedation– Better oxygen therapy– Better fever management,– Better setting of the ventilator knobs etc. etc.

With thanks to Prof Rinaldo Bellomo

Where are we heading with intensive care research?

Getting the basics right

Not too much, not too little, but

just right

Fluid Management

1. It’s not what you use but how you use it– No evidence of benefit for any one fluid over

another

2. Treat patient not numbers– Warm, well perfused, conscious, passing urine

3. Too much fluid as harmful as not enough

Single centre unblinded study by an enthusiast …

With an implausible outcome ……

And a huge effect on emergency medicine and intensive care practice

ARISE Observational Cohort study

• 32 sites, 324 patients, same inclusion criteria as Rivers

• Mortality– ICU 18.9% (n = 58)

– Hospital 20.1% (n = 62)

– 28-day 22.2% (n = 72)

– EGDT Study 46.5% standard arm, 30.5% EGDT arm

Arterial line 44.4%

CVC 37.0%

ScvO2 line 0%

NA or Ad 29.9%

Blood 7.7%

Hct T0hr 37 (19 - 66)

Hct T6hr 33 (19 – 48)

Dobutamine 2.5%

Inv Vent 18.8% ARISE interventions

T0 toT6 hr

1550 (0 - 9030) ml

412 (0 – 3500) ml

Fluids

Median,range

Arterial line 44.4%

Std 100%, EGDT 100%

CVC 37.0%

Std 100%, EGDT 100%

ScvO2 line 0%

Std 0% EGDT 100%Total fluids 2431 (1951) ml

Na or Ad 29.9%

Blood 7.7%

Dobutamine 2.5%

Inv vent 18.8% HOW DO WE COMPARE TO

the EGDT study?

Std 3499 (2438) ml

EGDT 4981 (2984) ml

Std 30.3%, EGDT 27.4%

Std 18.5%

EGDT 64.1%

Std 0.8%, EGDT 13.7%

Std 53.8%

EGDT 53.0%

Mean(SD)

Three large international trials now underway

• ARISE (Australia and New Zealand)

• PROMISE (United Kingdom)

• PROCESS (USA)

Message no 1

• A single centre trial by an enthusiast should not change practice …..

• …… no matter how good the results are ……• until it has been validated in a multicentre

environment• How do the results apply to YOU in YOUR

hospital?

Fluid Management - Summary

• Resuscitation fluid as necessary• After resuscitation, titrate fluid as necessary to

CLINICAL end points• Too much fluid can harm

– Tissue edema, organ failures– Pulmonary edema, ventilation failure

• Beware the ‘accidental’ fluids

Pain, sedation, delirium

• Three separate concepts which should be managed separately [2012 SCCM guidelines]

• Many ICU patients just need pain relief– Usually an opioid, by bolus or infusion

• If agitated, look for the cause– Uncomfortable or itchy– Full bladder?

Sedative drugs

• Growing evidence that benzodiazepines cause long term problems– Neuropsychological problems– Post traumatic stress disorder

• Increased volume of distribution and impaired clearance in critical illness– Midazolam is not a ‘rapid offset’ drug after an

infusion

Sedative drugs

• Sedative doses should be minimized to achieve a goal of light sedation– Calm but responsive to voice– Regular assessment of sedation depth– Consider daily interruption of sedation

• Delirium– Non drug approaches?– Specific drug therapy for delirium

• Observational cohort study in Australian, New Zealand, Malaysia

• Planning large RCT comparing an ‘anti delirium’ sedation protocol with usual practice

Extubation Time Mortality

26Wean ventilation as clinically tolerated and proceed to Extubation once clinically feasible

InterventionarmTitrate to maintain

RASS -2 to +1

RASS Q 4 hrs

CAM-ICU daily / twice

Dexmedetomidine

Conventional arm

Propofol

Morphine or fentanyl

Expected Ventilated > 24 hours, Sedation / Opioids

Randomise

Dependent on baseline care from

observational study for drugs and trials

Breakthrough agitation

Breakthrough delirium

Breakthrough agitation

Breakthrough delirium

Sedation - Summary

• Think about Pain, Agitation, Delirium as three different concepts, all treated differently

• Patient safety comes first• Calm and cooperative patient ideal• Excessive sedation associated with longer time

on ventilator, longer time in ICU, post-traumatic stress disorder, and possibly increased mortality

Nutrition

• Any patient expected to be in the ICU “the day after tomorrow” needs nutrition– Commence feeds within 24 hr in this group

• Enteral is best – cheapest, most physiological

• Parenteral nutrition reserved for those who cannot tolerate enteral– expensive, risk of sepsis

• Need unit guidelines– Specific to your own environment and casemix– Even with guidelines, only expect 70 – 80%

compliance• Don’t forget nutritional deficiencies

– Thiamine

Nutrition

Blood sugar control

• Hyperglycemia is common in critical illness, and associated with worse outcomes

• ‘Intensive insulin control’• Large influence from single centre SICU study

in Belgium (van den Berghe, NEJM 2001)• Results not duplicated in MICU study

Blood sugar control - summary

• Single centre results could not be duplicated in large multicentre study

• ‘Intensive insulin therapy’ caused increased mortality

• Keep BSL in ‘high normal’ range– 6.0 – 10.0 mmol/l or– 110 – 180 mg/dl

Post Cardiac Arrest Management

Return of spontaneous circulation – what next?

Post cardiac arrest

• Emergency angiography and stenting?– Depends on local resources– Otherwise consider thrombolysis according to usual

criteria• Cardiogenic shock

– No clear benefit of any one inotrope or vasopressor– Titrate to physiological goals– Physical therapies (positive end expiratory pressure,

IABP)

Therapeutic hypothermia

• We know that HYPERthermia is bad in brain injury

• Two trials suggest neurological benefit with either 12 or 24 hours moderate hypothermia– 32 to 34oC– Ice packs, cold fluids, cooling jackets

• ILCOR recommendation• Adverse effects of hypothermia

– Coagulation, electrolytes, cardiac function

TTM trial

Comparison of hypothermia with NORMOthermiaafter cardiac arrest?

Summary - hypothermia

• Fever is bad in brain injury• Likely benefit of hypothermia in subgroups

studied– Don’t forget exclusions– VF/VT cardiac arrest only– Not cardiogenic shock– Problems with drug metabolism – suppresion on

hepatic metabolism

Prognosis after cardiac arrest

• Used to be relatively simple– Levy criteria (JAM 1985)– No chance of regaining independence:

• No pupillary light reflex• 24 hr motor response worse than flexor and no

coordinated eye movements• 3 day motor response no better than flexor• 1 week not obeying commands ….

Wijdicks et al, Neurology 2006;67:203–210

Wijdicks et al, Neurology 2006;67:203–210

Prognosis in Hypothermia Era

• None of the ‘old’ tests validated• Confounded by need for sedation to tolerate

hypothermia– Too much sedation, slow metabolism, saturation

of fat stores• Evidence that therapy is being withdrawn too

son in patients with a good prognosis• But how long to wait?

PROPAC II

• Multicentre prospective cohort study in Netherlands to investigate the reliability of prognosis after cardiac arrest treated woth hypothermia

• Diagnostic methods – neurological examination,– neuron specific enolase (NSE) – median nerve somatosensory evoked potentials (SEP)

• Outcome– 53% poor outcome; patients die in first week

• Prediction poor outcome– Absent brain stem reflexes FPR 1 – NSE > 33μg FPR 7-10– SEP normothermia FPR 0

Conclusions – Post Resuscitation Intensive Care

Conclusions - 1

• ‘Not too much, not to little, but just right’• Be cautious applying magic therapies from

single centre studies elsewhere in the world• Know your own environment, epidemiology

and resources

Conclusions - 2

• After resuscitation over, give just enough fluid to achieve clinical endpoints– Too much fluid as bad as not enough– Choice of fluid much less important

• Sedate intelligently– Treat pain, agitation and delirium separately– Oversedation harmful

Conclusions - 3

• Early nutrition recommended– Use enteral route if possible – Don’t forget thiamine and treat other nutritional

deficiencies• Keep blood sugar ‘high normal’

Conclusions - 4

• Post resuscitation from cardiac arrest– Treat the heart as indicated (PTCA or thrombolysis)– Hypothermia for subgroup of patients shown to

benefit– Adverse effects of hypothermia– Be very careful with drugs and hypothermia

Conclusions - 5

• Prognosis after cardiac arrest is really hard in the hypothermia era

• Make no decisions until– Normothermia– You are confident of drug clearance

• Compassionate approach to patient and family in social context

seppelt@med.usyd.edu.au

Questions?