Neuro Resus

A quick interview with Mark & Lee from Developing Emergency Medicine giving some information about the 2018 Developing Emergency Medicine conference in Fiji. The conference will be held ath the InterContinental Fiji Golf Resort & Spa on Nataola Bay, from Monday 3rd December - Thursday 6th December 2018, with the two day ultrasound workshop the weekend prior.

Liver disease in ICU – when to stop? by Professor Julia Wendon

Hepatic resections are complex surgical procedures harboring a significant risk for complications. In line with the continued development of liver surgery, hepatic resections tend to be more complex and extensive, with to this associated enhanced risk for post-hepatectomy liver failure (PHLF). Despite these improvements in outcome after major liver resection, PHLF remains one of the most serious and fatal complication of major liver resection occurring in up to 8 % of the cases. Multiple factors increase the risk of PHLF but in clinical practice the risk of PHLF is closely associated with the assessment of the pre-operative Future Liver Remnant (FLR). Accordingly the prevention of PHLF is alleged to be affected by the induction of hypertrophy of the liver remnant via portal vein embolization or ligation if the expected functional left remnant in cases where the FLR is judged too small. An alternative therapeutic strategy is to perform a two-stage procedure allowing the FLR to grow after the first non-curative resection. Irrespective of these surgical-technical advancements, early recognition and initiation of supportive care is crucial to improve patient outcomes in PHLF. Despite its fatal consequences, the complexity behind the pathogenesis of PHLF remains poorly understood and treatment options (except for preventive measures) are limited. The advent of extra corporeal, albumin-based liver-dialysis system (Molecular Adsorbent Recirculating System, MARS) seemed to offer a treatment modality for patients with liver failure being either acute or acute on chronic (ACLF). The information on the use of MARS in PHLF is meager and basically no experiences have been reported with the use of well-defined criteria for liver failure. For instance Van de Kerkhove et al. reported on five patients treated with MARS due to unspecified PHLF, of whom 3 improved but only one survived. We have recently compiled our experience with MARS treatment for well-defined PHLF and found that four out of 13 patients survived (31%) three months postoperatively. However, this survival figure rose to 44% (4/9) if the analysis was confined to patients with primary PHLF fulfilling the Balzan criteria alone. These results formed the basis of a prospective clinical trial with the objective of evaluating early and consistent MARS treatment in patients with primary PHLF. Results from this study will be presented and discussed References Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The "50-50 criteria" on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Annals of surgery. 2005;242(6):824-8 Stange J, Mitzner S, Ramlow W, Gliesche T, Hickstein H, Schmidt R. A new procedure for the removal of protein bound drugs and toxins. Asaio J. 1993;39(3):M621-5. Gilg S, Escorsell A, Fernandez J, Garcia-Valdecasas JC, Saraste L, Wahlin S Nowak G, Stromberg C, Lundell L, Isaksson B. Albumin dialysis with MARS in post-hepatectomy liver failure (PHLF): experiences from two HPB centers. Surgery Current Research, 2015, 6: 252.

Management of the patient with decompensated liver disease is clearly more straightforward in specialist centres with multi-disciplinary input, access to liver transplantation teams and advanced technology. Bioartificial extra-corporeal liver support systems are undergoing evaluation and include the extra-corporeal liver assist device (ELAD developed by Vital Technologies). ELAD is an investigational, extra-corporeal, human cell-based system. The human liver-derived cells (VTL C3A) may mimic certain functions of in vivo human liver cells. The principles of operation of the ELAD system are as follows: plasma ultrafiltrate is passed through hollow fibre cartridges containing human liver-derived cells (VTL C3A cells) and allowing two-way transfer of toxins, metabolites and nutrients, mimicking liver function. Toxins, such as bilirubin, glucose and oxygen pass from the ultrafiltrate to the VTL C3A cells. Treated plasma ultrafiltrate is then reconstituted with blood cells and returned to the patient. Data evaluating this system shows trends indicating a potential for ELAD to increase survival rates in selected patients with decompensated liver failure. Issues in the management of liver failure include cardiorespiratory support, and the management of cerebral oedema. The principles for haemodynamic support are as for most critically ill patients, with early restoration of organ perfusion and use of vasopressors if hypotension persists despite restoration of volume. For the patient with liver failure, lactate-containing solutions and fluid overload should be avoided. New monitoring techniques for encephalopathy have been developed, including brain tissue oxygen tension, continuous EEG, transcranial Doppler and cerebral microdialysis. Key issues for regional centres are basic management principles, liaison with specialist centres and timing of transfer. Who and when to refer is a difficult problem for the regional Australasian unit, given the tyranny of distance and issues relating to retrieval and transfer of the critically ill patient. Early liaison with the regional liver unit is key.

The patient with chronic liver disease presents a range of potential challenges when a severe intercurrent illness occurs or major surgery is required. Even well-compensated liver cirrhosis in high functioning patients renders such individuals vulnerable to a myriad of problems when physiological stressors occur. Severe acute liver failure is another clearly defined sydrome in which extremely rapid and complex multiple organ failure typically ensues. Whilst intensivists are familiar and adept with the management of other major organ failure, new acute liver failure or decompensated chronic liver disease is particularly difficult to manage due to the inherent breadth of roles that the liver has in maintaining health as well as the current lack of comprehensive support therapies other than organ transplantation. While effective artificial life-supports for severe respiratory, cardiac or renal failure are available in the intensive care setting, support for over liver failure is less straightforward. The failing liver inevitably and rapidly impact on every other organ system, necessitating a systematic and comprehensive approach when planning patient care. As with any dynamic and complex disease process, management is optimised when major clinical problems are anticipated and the detrimental impact is mitigated by the timely application of effective interventions. For patients with severe acute liver failure, a knowledge of the cause, disease trajectory, severity of organ failure as well as early interventions to prevent cerebral oedema are likely to improve outcomes. Specific treatments such as temperature management, respiratory support, osmotherapy and blood purification may be readily applied and reduce the risk of poor outcomes. In the setting of decompensated chronic liver disease, identifying reversible causes of deterioration and proactively managing the resulting predictable problems will ensure the best chance for recovery or stabilisation until subsequent transplantation. The majority of patients can be effectively managed in non-transplant centres, however it is also essential to identify those patients for whom orthotopic liver transplantation is the best or only option for survival. Early discussion with a transplant centre may assist intensivists in deciding who should be transferred and guide the timing of retrieval.

Despite the publication of a number of studies over recent years looking at energy delivery and outcomes in the critically ill population we remain uncertain how best to determine optimal calorie delivery for our patients. The concept that energy delivery should match energy consumption is plausible and intellectually attractive bu Broadly speaking clinicians can be divided into 3 categories according to their approach on energy delivery to the critically ill. Some believe that optimal clinical outcomes are achieved by closely approximating energy consumption i.e. providing full calorie requirement, usually around 2000kcal/d for the standard sized adult. This position is supported by a number of observational studies, however, patients usually only receive about 60% of what they are prescribed. Some believe that attempting to provide full feeding exposes the patient to the risk of overfeeding and that 'permissive' underfeeding is safe and better tolerated in critically ill patients where gastrointestinal function is frequently deranged. Interestingly, recent data suggest that the patient group potentially most at risk of overfeeding are those who are malnourished at presentation. Finally, some believe that the amount of energy delivered during ICU stay has little impact on recovery. Only when the ICU stay becomes unusually prolonged may the amount of energy delivered become important. There is evidence to suggest that some nutrition should be given enterally from early in the ICU stay to provide gastrointestinal mucosal protection and improve subsequent gut function. In recent years there have been several randomised controlled trials addressing energy delivery but they have unfortunately given conflicting results. Furthermore, these studies have had a number of limitations including: being underpowered to show an effect on survival; open to bias because of being open-labelled; most have not delivered full energy requirements so the effect of this on outcomes remains uncertain. It is hoped that many of these issues will be addressed in the currently recruiting TARGET trial which will be completed next year.t, while energy delivery can be measured with indirect calorimetry, this is not a technique that lends itself to routine clinical care. Accurate measurement or calculation of day to day energy expenditure is not currently routinely possible. Delivery of nutrition is an important supportive activity in the ICU. Patients generally receive less than prescribed nutritional needs and there is no robust evidence as yet to suggest that this is deleterious to outcomes.

by Professor Jas Samra

The 105 years since the first successful thoracic oesophagectomy was performed saw initially slow progress in terms of operative mortality, morbidity and oncological outcomes. Even until the late 1990's, operative mortality figures of 15-20% were commonplace and long term survival was poor, as low as 12%1. The last 20 years has seen a major change in these outcomes both within Australia and overseas. These improvements have been based on the bed rocks of improved surgical techniques, improved peri operative care, changes in the distribution of the pathophysiology of the disease, improved patient selection through better staging, Development of endoscopic techniques for early tumours, development of effective neo adjuvant regimes and the development of "high" volume centres have all contributed to the current figures of 4% preoperative mortality and overall 5 year survivals in the post surgical patient of 40%. Better understanding of the nutritional issues involved has led to an emphasis on better quality of life issues in both the curative and palliative settings. This talk outlines the forces that have brought about the changes including outlining the modern treatment algorithm and discussing the volume effects of surgery in the Australian context 1. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67: 381-90

Role of endoscopy in upper GI bleeds by Professor Michael Bourke