Coda Change

Simon Finfer explains the future of sepsis treatment focusing on life after surviving sepsis.

Sepsis is the life-threatening condition that arises when the body's response to an infection damages its own tissues and organs. It can lead to shock, failure of multiple organs, and death.

Organ failure and death are more likely if sepsis is not recognised early and not treated promptly.

Sepsis is the leading cause of death from infection around the world and contributes to or causes half of all deaths occurring in hospitals in the USA. Many people who survive severe sepsis recover completely and their lives return to normal.

But some people, especially those who had pre-existing chronic diseases, may experience permanent organ damage, the common problems that afflict those who have recovered from sepsis have been termed the post-sepsis syndrome.

They include sleep disturbance including insomnia and nightmares. People experiences hallucinations, flashbacks and panic attacks. Muscle and joint pain occur, which can be severe and disabling.

Similarly, functional impairments such as extreme tiredness and fatigue, inability to concentrate and impaired cognition occur. These effects even extend to a loss of confidence and self-belief.

The global medical community has improved sepsis survival. Because of that, Simon contends that all these long-term effects of sepsis must be paid attention. The current trials overwhelmingly look at survival.

The future of research therefore should include post-sepsis outcomes. For instance, Simon asks the question – are these long-term effects due to sepsis, or rather, are they due to being in the ICU.

Simon discusses the future of sepsis care. Specifically, he discusses the idea of post-sepsis care and follow up.

Much like there is respiratory follow up following an acute episode of respiratory disease, Simon believes there needs to be dedicated care for sepsis survivors.

As he explains, the acute treatment of sepsis is the beginning of the road.

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Alistair Nichol explains the use of hypothermia in the treatment of traumatic brain injury (TBI).

TBI is a major cause of mortality and long-term morbidity. It leads to terrible outcomes and is a major cause of health burden across the globe.

Prophylactic hypothermia presents a promising treatment to address this hidden epidemic. The pathophysiology of TBI is exceedingly complex.

Evidently, one drug will likely not be the answer. This leads Alistair to discuss hypothermia as a treatment for TBI, which has huge potential benefit.

As Alistair explains, it acts in many different places, in many ways, across many time periods. Could this be the 'drug' to give?

The questions then become, when should you give it, how should you give it and how low should you aim?

In the case of TBI, this means at the roadside if practical. How low should you go?

Given the effect of hypothermia on coagulation, and the propensity for trauma patients to bleed, this is a tricky question. Alistair states that 32 degrees is ideal however this leads to further haematological complications.

To that end, 35 degrees is a sensible aim, to then go lower once bleeding has been excluded in the Emergency Department.

How do you do it? Ice is unfavourable, given the difficulty of controlling the temperature and the adverse effects including ice burns. Alistair also warns against the use of ice cold saline due to the effects of positive fluid balances in TBI patients.

Alistair explains the current methods, such as surface cooling pads and intravascular cooling catheters. It is not a risk-free treatment. Risk of infection rises due to effects on cellular processes. Propofol-related Infusion Syndrome (PRIS) is also being increasingly recognised as an adverse outcome.

Finally, the re-warming following hypothermia is risky. Alistair explains the complex process of re-warming.

Alistair concludes by explaining the current trials underway and the potential future for this treatment.

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Ryan Radecki urges you to rethink the acute management of stroke.

The current way of thinking about stroke and the acute treatment has been around for decades. In this time, a lot has changed, new technologies have been developed and we have learnt a lot about the underlying physiology of stroke.

Endovascular therapy, CT perfusion, and patient-level predictive modelling are now all at the disposal of clinicians.

Moreover, Ryan wonders if we are using the current treatments – namely tPA – more safely or effectively. In acute stroke management there are two key factors to consider. Successful reperfusion and salvageable tissue.

To restore and save brain tissue one must successfully re-perfuse the tissue. The classic method for achieving this is by using tPA.

It is a dangerous drug, with many risks, and it is not appropriate for all patients. Salvageable tissue is the second key factor. If brain tissue is dead, it stays dead. It does not matter what drug you give.

Evaluating this tissue makes sense. To this end, Ryan believes that new technologies can be better utilised. As he sees it, some of the new advances in stroke care do not recognise the underlying pathophysiology of the problem. They just deliver pre-historic care, faster.

Further, he argues that the new advances do not individualise care. So, what should be done? Ryan explains that perfusion imaging makes sense, as every patient has unique cerebrovascular anatomy.

The goal should not be to give more patients tPA but to give it to patients who have the best risk-benefit ratio. He argues against expanding the treatment population for tPA against rational judgement.

Moreover, the goal should be to tailor evaluation to identify the patients that will benefit from this intervention and to identify patients who should be put onto a different pathway. Aim to individualise care with the available technology and investigations.

Finally, Ryan discusses the clinical trials underway, which may produce zero, subtle, or huge changes in practice.

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In this entertaining talk, Ronan O'Leary discusses conflict in critical care.

Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy.

Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care.

Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don't know when, or even how.

Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play.

Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches?

Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either.

An important component will be the future structure of clinical training. Our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts.

Ronan posits that training should involve exposure to collegiate decision making and consensus building.

However, this will be difficult to achieve within our current nationally co-ordinated training schemes.

How to manage conflict in Critical Care: Ronan O'Leary

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Martin Smith persuades you that controversies in brain death should not, and do not, exist.

Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification.

Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain.

Martin provides a history of the concept of brain death. He describes how advances in modern medicine have made the concept of death, and specifically brain death, muddled. This has broad implications on the diagnosis of brain death – and provides the basis to the controversies that exist.

The idea, and in fact the truth, is that death does not happen at a discrete moment in time.

Alive or dead may be the only two states an organism can be in. However, the transition from one to the other is not instantaneous.

Martin contends that the process and the nomenclature has little practical relevance. What is important is the point of irreversibility.

He explains how we, as a medical community, can be confident of this point.

The main points are 1) fulfilment of essential preconditions, 2) exclusions of reversible causes and 3) clinical evaluation.

In his talk Martin elaborates on each and provides some important teaching points. As he explains, this is an important concept to grasp as it has implications for your patients as well as broader societal implications in the context of organ donation.

Martin's talk will discuss the history and development of the concepts and diagnosis of brain death internationally. He examines current challenges and controversies and makes the case for an international consensus.

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Hazel Talbot gives her insights from working in neonatal and paediatric retrieval.

She delivers her talk with all the passion and dedication that she brings to her work as a neonatal and paediatric transport consultant.

Equipment failure, rapidly deteriorating children and miscommunication are all common challenges that Hazel and her team encounter in their line of work. This is on top of the challenge of caring for neonates and children.

In this talk, Hazel focuses on physiology and disease. The large majority of young deaths in the UK, where Hazel works, are neonates – under 28 days old.

50% of these deaths are due to perinatal diseases. These include congenital malformations, prematurity, sepsis, and congenital heart conditions.

Children are small adults. Small airways, small necks, small lungs. Babies however are not small children. They use the majority of their physiological ability to survive.

When they breath they use most of their diaphragm, compared with an adult who will only use a small proportion. This leaves babies without much reserve. They have a high metabolic rate, and neonates have a right heart dominance with an inability to change their stroke volume.

Hazel urges you to consider this when faced with a sick baby. When thinking about neonatal and paediatric retrieval, Hazel has some key points. Practice, anticipation and knowing your environment and equipment is key to a success outcome.

Hazel drives this message home with a case presentation. This example highlights not only Hazel's skill and knowledge, but also her ability of communication, leadership, and intuition.

Join Hazel as she gives an insight into her amazing work in neonatal and paediatric retrieval. Come along as she discusses her experiences and tells you how to ward of the Evil Transport Fairy!

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Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care.

These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L.

He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups.

Simon continues by raising further research to justify his position.

Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does!

As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue.

Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad.

So surely there must be a "right" number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important.

Join Oli and Simon as they debate on this important issue.

When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer

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Myths persist because they are essential to the human experience and our development as a society. They fill the gap between what we know and what we think we know. Where does this gap hurt us the most? In our vulnerable populations, for example, in our care of children. The "myth incarnate" in medicine: defective dogma. Not all dogma is bad – after all, dogma means "that which is believed universally to be true". The problem with medical dogma is that our critical thought processes are curtailed by wholesale acceptance. Medical dogma is a special kind of myth, because it's difficult to define. We repeat defective dogma for three reasons: "It is known". Sometimes the dogma is all that is known on the subject, or it is simply the majority consensus. Be careful with this one – because there may be a reason for this specific teaching – not all dogma is bad. Dogma is sentimental. We learned from our teachers who learned from their teachers. We want to honor those who taught us, and we get attached to some ideas. Sometimes – even subconsciously – we allow our attachment to an idea to give it more credence than it deserves. The third driver of dogma is insecurity. "I know what I know". In other words, "don't make me reveal my limitations." Myth: "They're all fine" Remedy: Remember to look for the subtleties in children. Early warning signs are there, in the history or in the physical exam. If it doesn't add up, investigate. Myth: "Only pediatricians are experts" Remedy: Don't delegate decisions. You can do this. You sometimes are the only one that can. Myth: "I will break them" Remedy: Children are not another species. Use all of your skills for all of your patients" Powered by #FOAMed – Tim Horeczko, MD, MSCR, FACEP, FAAP

Ffion Davies gives her take on how to spot the sick child in the Emergency Department.

Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion's opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.

So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.

In this talk, Ffion gives a lesson on how to spot the sick children in the 'grey' zone – those that are not clearly sick and not clearly well.

Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child's age) will help avoid the feared crime of discharging a sick child.

Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one's suspicion of serious disease.

Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.

Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.

Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.

Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.

Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.

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In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. The TRansfusion and TReatment of severe Anaemia in African Children: (TRACT ISRCTN84086586) is a 3x2x2 factorial controlled trial involving 3954 children (aged 2m to 12y) with severe anaemia (haemoglobin If confirmed by the trial, a cheap and widely available 'bundle' of effective interventions could lead to, if widely implemented, substantial reductions in mortality in African children hospitalised with severe anaemia every year. The trial started in Sept 2014 and currently 2700 children have been enrolled. We expect the trial results to be available in 2017.