Neuro Resus

To pass the Second Part Exam, your performance needs to be at the expected level for a junior consultant. You need to be able to rapidly synthesise clinical information from multiple sources to reach a differential diagnosis and appropriate management decisions. (And achieve this while feeling the equivalent of standing at the top of an Olympic downhill ski-run, simultaneously suffering from a severe bout of gastro.)

Some general pointers include:

Get experience running the unit and calling the shots

Establish a good knowledge base - don't just practice SAQs

Write and share your own SAQs and Vivas

Make every case you see at work a practice Hot Case

Teach everyone else

Consider performance coaching

Finally, if things don't go to plan the first time, remember it's an exam not a statement on who you are as a person. Work out what worked and what didn't and why to change your approach and come back stronger.

Tips and tricks for getting through the first part: Examiner's perspective

10% of patients admitted to ICU die and, in some societies over 80% of people die during a hospitalization that included an ICU stay. Most deaths in ICU are predictable and the overwhelming majority of patients are comatose for the last few days of their life. Most communication by intensivists is directed at families rather than patients. This talk will cover some scenarios where this isn't the case and give guidance on delivering bad news to and discussing organ donation with awake patients.

According to the World Health Organization Training Package for the Health Sector (2008), 'Children are not little adults' and specialised care must be targeted to pediatric patients in order to optimize outcomes. In a review of Australia and New Zealand Paediatric Intensive Care (ANZPIC) Registry data from 2006 to 2016, approximately 1600 children 11 year period, 15 727 (89%) were discharged home directly, 330 (2%) died in the adult ICU, and 1625 (9%) were transferred to tertiary PICU for ongoing care. This data suggests that modern Australia and New Zealand adult ICUs provide a significant proportion of Intensive Care therapies to Australasian children. In this session we will discuss some of the key anatomical, physiological and developmental differences of relevance to critical care of the infant and child. In particular, the translation of common intensive care principles will be highlighted to empower well trained adult intensive care physicians to apply their skills and knowledge to critically ill children.

You are called to see a 62-year old male now 3 hours post CABG x 4 with hypotension and escalating vasoactive requirements. As you arrive to the bedside, he arrests. How do you manage this situation?

This talk outlines the management of cardiac arrest in the intensive care unit post open heart surgery, as per the CALS (Cardiac Advanced Life Support) algorithm. Key differences from the standard ALS (Advanced Life Support) algorithm are highlighted, including delaying CPR by up to 1 minute to troubleshoot the initial rhythm, the role of emergency resternotomy, and avoidance of 1mg doses of adrenaline.

The prevalence of degenerative valvular disease is increasing in the context of an increasingly ageing population, and despite advances in medical and surgical interventions, is associated with a significantly worse outcome when compared with the general population. Data from the EuroHeart Survey (2003) suggests the commonest relates to native valve disease (predominantly aortic stenosis) however, more than one quarter of patients with valve disease have undergone a previous intervention. According to current guidelines, in general treatment for severe, symptomatic aortic stenosis is surgical aortic valve replacement, which is associated with excellent outcomes, however, despite this around 30% of such patients do not undergo surgical intervention.

The last decade has seen a significant change in the potential therapeutic options for patients with aortic valve disease due to the development of transcatheter techniques for valve implantation. Patented in 1991, the first successful human implant of a transcatheter aortic valve was undertaken in 2002, with currently >500,000 implantations having been undertaken in >70 countries worldwide. The evidence supporting transcatheter aortic valve implantation (TAVI) otherwise known as transcatheter aortic valve replacement (TAVR) came originally from the key PARTNER studies, where patients judged to have inoperable aortic stenosis who underwent TAVI having improved survival and a reduction in hospital admission at 1 year. Following the early safety and efficacy studies, and following increasing recommendations for TAVI as an option for patients at high risk in international guidelines, the use of transcatheter techniques is extending to those of lower risk.

The title of the talk is emblematic of the binary way that we have approached structural heart disease where cardiac surgery or an interventional procedure might be required – this thinking is now transitioning to an entirely different paradigm which is that of the "Heart Team".

Remarkable advances over the last decade have led to a plethora of interventional options for both coronary and structural heart disease. In the coronary realm, as complex and high risk PCI options continue to evolve, the role for surgery in multi-vessel disease, diabetes and LV dysfunction has become well established. Hybrid revascularization options also evolve and are the subject of ongoing investigation. In structural heart disease, as TAVR application expands to a low risk subset, ongoing investigations will answer questions regarding durability of TAVR as compared to the historical surgical gold standard. Mitral valve repair remains the gold standard for degenerative MR and the Mitraclip has become a well-established option for a high-risk subset. Ongoing studies will answer the role of Mitraclip in functional MR and excitingly multicenter studies are investigating a role for transcatheter mitral valve replacement for mitral valve disease. The role of surgery in tricuspid valve disease, a large and underserved subset remains controversial and transcatheter devices remain investigational at this point. The reality is that decision-making is complex and central to the entire debate is the heart team concept, whereby surgeons and interventionalists sit at the same table as part of the same team to determine the best approach for any given patient. As evidence continues to evolve, lines between cardiac surgery and interventional cardiology continue to blur, with combined expertise from both sides going forward required to best serve our patients in a truly heart team approach.

CARDIAC REVASCULARIZATION SURGERY IN THE ELDERLY: AN EVIDENCE-BASED HEALTH ECONOMIC APPROACH

Background: Increasing prevalence of chronic disease in the context of an ageing society has led many to question the value of cardiac revascularization surgery and associated intensive care in elderly (octogenarian) populations. However societal expectations of improved technology and its likely impact on longevity and improved quality of life suggest there is a demand for cardiac surgery in this population. Elderly people are more likely to hold private health insurance, therefore the cost (in terms of waiting time) is likely to be low.

Objectives: This presentation will consider the value of cardiac revascularization surgery from a health economic perspective, including the various perspectives of patient, family/significant others, providers, healthcare sector and society.

Method: A theoretical evidence-based health economic model will be presented that is relevant to the evaluation of cardiac surgery in an elderly population. This will be combined with a review of the literature and existing data sources as evidence-based inputs into the development of an economic model to assess cost effectiveness in terms of cost per quality adjusted life year saved. Studies included will be recent published trials (post 2010) where costs and/or quality of life outcomes have been compared between cardiac surgery and conservative management in an elderly (80+ years) population.

Results/Conclusion: Recent literature and study results will be reviewed against the theoretical health economic model. Where evidence and/or data exist that meet inclusion criteria for the economic analysis these will be summarised in the model. Where gaps in evidence exist these will be highlighted, including appropriate strategies to address data deficiencies.

A/Prof Jennifer Watts

Health Economics

Faculty of Health

Deakin University

Introduction: Recent times have witnessed almost half, or sometimes more cardiac surgical procedures are performed in patients above 75 years of age. Traditionally, the EuroSCORE II and STS risk scoring systems have been widely used across the globe. Extensive reviews have shown that EuroSCORE II probably overestimates the perioperative risk at lower score levels while the STS score tends to underestimate the risk.

Frailty is a broad term that encircles aspects of nutrition, lack of agility, inactivity, lack of strength and wasting; and is seen in 25-50% of elderly patients. It has been defined as a geriatric syndrome reflecting a state of reduced physiological reserve and increased vulnerability to poor resolution of homeostasis after a stressor event. Conversely, pre-frailty, which is potentially reversible, is associated with higher risk of older adults developing cardiovascular disease.

Frailty assessment includes a variety of physical and cognitive tests, functional assessments and evaluating nutritional status. Literature has highlighted what is referred to as the 'obesity paradox', meaning obese patients with heart failure fair better than leaner patients, possibly because they have more metabolic reserve and also because weight loss in itself is a risk factor for frailty.

Patient Selection: To comprehensively assess a patient, factors that describe the biological status of the patient should be incorporated. There are various methods of assessment and modified Fried criteria or comprehensive assessment of frailty are a couple of systems commonly used.

Conclusion: Systematic reviews have shown that frail patients have higher chance of mortality, major adverse cardiac and cerebrovascular events and functional decline after cardiac surgery. A holistic assessment not only categorises patients into the apt risk category and hence match goals and treatments; but also, will pick up patients with pre-frailty who will benefit from multidisciplinary intervention and be better prepared for the intervention.

"The real benefit to the patient [of echocardiography] is not the technical skill, but rather the application of intellectual input... information, communication and teamwork are essential" Jos Roelandt, 1993

Of all the imaging techniques used in intensive care, echocardiography has come to the fore, in particular due to its accessibility, immediate availability and applicability as a point-of-care technique, thereby removing the risks of transportation of the critically ill. Over the preceding 20 years evidence has continued to emerge for its extended use in the acute/emergency setting, to the extent that it is now included in national and international guidelines relating to the universal definition of myocardial infarction, as well as in shock pathways, and as an adjunctive technique in advanced life support. Its potential scope is huge, with applications relating to monitoring, cardiac pathophysiology and coronary perfusion as well as its more evident use to define cardiac anatomy.

The three main uses of ultrasound to interrogate the heart relate to the way in which the technique is used: first, as an extension to the clinical examination using binary questions and 2D imaging only (focused cardiac ultrasound, FoCUS) which forms the basis of 'basic' techniques. Second, incorporating the full range of echocardiographic techniques for diagnostic capability (echocardiography), and third, selective application of the full range of techniques in order to answer specific questions raised in the critical care/emergency arena (targeted echocardiography). This includes speckle strain/strain-rate to determine abnormalities of myocardial function suggestive of myocarditis, calculation of myocardial electromechanical efficiency in order to maximise cardiac output, recognition of parameters that suggest restrictive right ventricular physiology, with the requirement for modification of ventilatory techniques and parameters, detection of myocardial ischaemia, estimation of LVEDP and LAP, and its application in the institution, monitoring and weaning of mechanical circulatory support.

Key questions for the clinician undertaking echocardiography in the critical/acute/emergency setting can be summarised in a checklist format, which includes:

Background questions:

1. What is the clinical context?
2. What does the treating clinician want to know (ie why won't the patient wean from mechanical ventilation? or is this pulmonary oedema, and if so, why?).
3. Can echocardiography answer the required question, and what is the accuracy in this setting?
4. What is the underlying diagnosis (cardiac and non-cardiac)?
5. How is the patient being sedated/ventilated/supported

Specific echocardiographic data:

1. What is limiting the cardiac output/elevating the venous pressure?
2. Is the left atrial pressure elevated?
3. Is the heart rate/AV delay/VV delay appropriate?
4. Is there any other relevant information that the treating clinician needs to know that may inform planned interventions?

To reach its full potential in the critical arena demands therefore not only understanding of the whole range of echocardiographic techniques, but also the confounding factors that will be found in this setting, including filling status, ventilatory parameters, mechanical support and the use of vasoactive agents. Although frequently 'simplified' for application in FoCUS, expert echocardiography in this setting can be extremely challenging, and the potential to cause harm to the patient through misinterpretation should not be underestimated.