Critical Care Medicine

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

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

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

Coming soon

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

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

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

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

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

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