Coda Change

Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how? To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation Drug Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs. Dose As Paracelsus famously said "The dose makes the poison" This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement. Duration When do you start and stop? You must weigh up the benefit and risk of fluid administration. Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved. De-escalation Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia. Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!) We need to make good fluids better So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D's and remember the four phases of ROSE.

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When looking into someone's abdomen, the first thing you'll notice is that it almost looks like there is nothing there. For Dr. Lauren Westafer, the gut looks like a black box. There's a lot of gas which makes it hard to see arteries and organs. In this podcast, Lauren discusses point of care Intestinal Ultrasound. To do an intestinal ultrasound, first, rub the curvilinear probe over the abdomen... That's it as far as technique is concerned! There is nothing overly complicated for such a useful procedure. Why do we still need an ultrasound for small bowel obstructions when we already have other tools like patient history, a physical exam, and x-ray? Unfortunately, these tools are all unreliable for diagnosing small bowel obstructions. What's more, the training for gut ultrasound doesn't take much time. It takes around 10 minutes to do 5-10 scans. The scanning procedure itself takes less than five minutes to perform. For such a high-value procedure, it takes an incredibly low amount of effort and time! When conducting a gut ultrasound, you are looking for dilated bowel (greater than 2.5 cm) and abnormal peristalsis. Lauren explains exactly what to look for, especially when recognising patterns of abnormal peristalsis. Lauren encourages us to embrace a gut ultrasound. From DAS SMACC, tune in to a discussion on Point of Care Intestinal Ultrasound by Lauren Westafer.

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Neil starts off by telling us a story about a plane that took off from JFK and flew to Portland. As they approached to land, they realised that they had a problem with the undercarriage. Instead of listening and taking advice from the flight engineer, who was on board and aware of the problem, the pilot chose to continue to fly the plane around in circles. This led to the plane eventually running out of fuel and a subsequent plane crash. Tragically, the plane crash killed multiple passengers on board, including the flight engineer. The moral of the story? Don't be the captain who doesn't listen and don't be the flight engineer who didn't speak up. Neil defines command gradient error as the actual or perceived difference in rank which inhibits communication, leads to a loss of the shared mental model and ultimately an undesirable event. We as healthcare professionals are doing much more to patients than we've ever done before. This sparks the need more than ever, to generate teams that are functional and collaborative. As we go through any single job, we may move between leading and following the situation. We should embrace this model of teamwork. Neil's advice for those leading is to be receptive. We should develop an environment that allows people to question our actions and decisions. When following, we should be assertive. After all, it is usually the people following that have the bandwidth to identify a problem in the first place. In this podcast, Neil Jeffers explains how Command gradient error in Prehospital Care can ultimately lead to tragic circumstances. We should focus on collaborative teamwork and clear communication to ensure that we avoid tragic outcomes for our patients.

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Cognitive offloading for critical care retrieval by Stephen Hearns Everyone's cognitive capacity is limited. It is easy to become overloaded and subsequently for our performance to be impacted. In medicine however, an overloaded cognitive capacity could be the difference between life and death. There is little room for healthcare professionals to be unfocused, yet retrieval medicine is comprised of unpredictability, critical time pressures and fast-paced emergency responses. Let's face it, there's never a time where we are more cognitively overloaded than at a multi-casualty incident. Cognitive overload in retrieval medicine results in an unsafe environment and compromised decision making. We need to rely on strategies and processes to reduce our cognitive burden. Eliminating the need to make decisions, allows for a better response to unpredictable scenarios. One strategy is to identify the predictable recurring components and plan for them. Practice implementing the plan, fine tuning the response and ensuring that the whole team is on the same page. It is critical that everyone is well versed and understands the processes and procedures. Furthermore, streamlining communication can have a significant impact on the outcome of high-pressured situations. It can also help us reduce stress and stay in control. Articulate and tell the team when you are overloaded. Encourage your colleagues to do the same when they are overloaded. Delegate and outsource decision making. Teamwork is critical and can make or break an outcome. Rely on writing lists and prioritising actions. It is an excellent way to seek clarity in high-pressured situations. Plan, practice and predict the predictable so that when the unpredictable happens, it has our full attention. Tune in to a DAS SMACC talk by Stephen Hearns on cognitive offloading for critical care retrieval.

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Critical care is viewed from different perspectives. How to clinicians, patients and families experience this life changing part of the health care system?

Jack Iwashyna discusses his research into persistent critical illness in the ICU. While much of resuscitation focuses on the dramatic early minutes to hours of critical illness, many patients stay for days or weeks in the ICU. Jack wants to know, why do patients get stuck in the ICU, and what might we do better to improve their care? Jack became an ICU doctor because he loved drama. He wanted to find the golden hour. The golden hour describes the time to intervene, to make a difference, and to save people's lives. It is an extraordinary thing to be able to do this, and it is sometimes possible. However, sometimes, it is not. Sometimes the golden hour is not there. Jack describes his experience with patients who would come into the ICU unwell. They would be treated aggressively and begin to get better. However, they would then take a turn for the worse. He describes this as a chronic critical illness. His patients were stably critically ill, and he could not work out why. This led Jack on a sabbatical year where he was afforded the opportunity to try to make sense of these people. The first question he and his team answered was, among patients who spend a long time in the ICU, how common are new, late organ failures? They discovered that in patients who are in the ICU longer than 14 days, there is an average of two new organ failures. Subsequently, Jack developed the persistent critical illness hypothesis. This states that there is a point in the ICU stay beyond which the ICU admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death. Put simply, the patient that you treat on Day 1 in ICU is different to the patient you are treating on Day 10. After Day 10 who the patient was before entering ICU matters more than what put there in the first place. Therefore, persisting critical illness defines those patients whose current reason for being in the ICU is more related to their ongoing critical illness than their original illness that took them to the ICU. Jack extrapolates his ideas surrounding persistent illness and critical care. In doing so, he raises thought provoking ideas regarding the long stay patients in the ICU.

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After getting his chance to interrogate SMACC Superstars the people finally get their chance to get their own back as everyman Iain Beardsell asks the questions that everyone wants an answer to. Covering a wide range of topics it will focus on Peter's previous SMACC talks, including subjects such as teamwork and burn out and no doubt reliving his interviews across the week.

The ethics of incidental findings: James Rippey Ultrasound is an incredibly useful tool for clinicians. According to James Rippey, there are two main groups of clinicians who use ultrasound. First, there are the POCUS providers, who have a specific, focused question and use the ultrasound machines accordingly. Then, there are the ultrasound experts, who look beyond the specific questions and embrace ultrasound as a valuable diagnostic tool. The advancement of high quality, handheld ultrasound machines means that we will all have imaging available at our fingertips. Notably however, questions are raised regarding the impact that these machines can have on families and the ethics behind incidental findings. James shares a personal story about how using a handheld ultrasound machine on his son, incidentally found a retroperitoneal tumor. Luckily James's son survived, however it raises questions as to the risk-benefit ratio in the discovery of an incidental finding. This extends not only to the likelihood of the finding being serious but also to consider the financial and emotional costs of incidental findings. It causes us to consider Ethics in Healthcare and the value of procedures that can be unnecessary. For those practicing POCUS (the simple single question, focused form of bedside ultrasound) James's suggestion is to remain focused and not be distracted by incidental findings that you are not qualified or taught to recognise. Communication regarding the limitations of your scan is far more important. For those clinicians with advanced ultrasound education, James encourages you to identify and consider any incidental findings you come across while performing an ultrasound. Rely on the help of other experts to guide interpretation of incidental findings where appropriate. Tune in to a DAS SMACC talk by James Rippey on the Ethics of Incidental Findings.

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Critical Care survivors: Margaret Herridge In this podcast, Margaret Herridge considers this well-known quote from Nietzsche, "That which doesn't kill us makes us stronger." But… Does it? What about our patients who suffer from a critical illness? The continuum of critical illness and what lies ahead for recovery should not be underestimated. Post critical illness, it is not uncommon for patients to suffer from a functional disability, a neuropsychological disability, or a decline in their general sense of wellness and vitality. Patients who have suffered from a critical illness regularly have trouble trying to reintegrate back into normal life. What about the mental illness concerns for both patients and their families post critical illness? We know that post traumatic stress disorder is common for recovering patients and their families. So… knowing this, are our patients actually stronger post illness? Traditionally, the focus of critical care has simply been on keeping patients alive. This is not enough, now we need to focus on giving them their lives back too. We need to make sure that we know our patients and their families and that we help people understand the continuum of illness and recovery. We need to make sure that the treatment which we deliver every day aligns with the goals and values of our patients and their families. We must know them in order to understand this. Margaret explains post traumatic growth as a change in the perception of oneself, a change in the experience of relationships or a change in one's life philosophy. So... post critical illness perhaps there is an opportunity for growth and this is a positive outcome, however we must not underestimate what it means to be a critical illness survivor. From DAS SMACC, Margaret Herridge delivers an inspirational talk on what it means to be a critical care survivor.

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David Menon discusses the complex and fraught world of managing traumatic brain injury (TBI) in the ICU. In particular, David discusses the management of intracranial pressure and cerebral perfusion pressure in these patients. Although the Brain Trauma Foundation provides guidelines for the management of severe TBI, including targets for ICP and CCP, there is no Level 1 recommendation for the use of any intervention to modulate ICP/CCP. General principles remain simple in theory, if not in practice. David describes good basic intensive care, which he describes as doing lots of little things well. The main focuses should be maintaining blood pressure high enough to get oxygen to brain, optimising oxygenation and modulating carbon dioxide. This is in combination with other modalities such as hypertonic saline, cooling people, and using metabolic suppression. The trouble lies in the fact that there is no evidence base for second line therapy. In fact, some of these therapies have been shown to cause harm. When considering a therapy, it boils down to this - is the disease desperate enough and have the benefits and risks of therapy been weighed up. When controlling ICP, the indications for treatment are different so acceptance of iatrogenic risk must also change. Therefore, ICP treatments must be calibrated using a risk benefit ratio. For instance, utilising hyperventilation to decrease intracranial pressure can be a useful lever to pull. However, going too hard can reduce the cerebral blood flow to a detrimental point. The point here is to use it briefly, to make time for another less potentially harmful intervention. Similarly, when considering CCP, targets and protocols use population averages. No single optimal CCP exists across all patients. So, clinicians need a rationale way to titrate treatment to physiology. David suggests using graded thresholds to escalate treatment in an individualised way. Underlying these principles is good detection and minimisations of treatment harm. Underlying all of these principles is a grounding in the data and the utilisation of this data to effectively communicate with families. By doing this you can deliver the treatment and aim for the outcomes deemed most acceptable by the patient and their loved ones.

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