Neuro Resus

Monoclonal antibodies (MAbs), guided by molecular studies and personalised medicine are changing the face of clinical medicine. They hold the promise of controlling diseases and improving survival whilst reducing the side effects of some 'traditional' therapies. MAbs are being used in conditions familiar to intensivists such as asthma, invasive candidiasis, RSV infection, reversal of novel anticoagulants and clostridium difficile infection as well as in those less commonly seen by intensivists such as multiple sclerosis, migraine, rheumatoid arthritis and numerous malignancies. Side effects of MAb treatment pose particular challenges for intensivists and range from cytokine release syndrome to autoimmune states (such as colitis, endocrinopathies, skin reactions), pneumonitis, thromboemboli, and infections. Pharmcokinetic interactions of MAbs with other drugs remain poorly studied and may be immune dependent, cytokine dependent or target dependent. Our traditional approach of triaging patients for ICU, based on organ failures and 'prognosis of underlying disease' is going to be challenged by MAbs with their disease modifying properties and unique side effects.

The incidence of cancer is increasing in line with our ageing population, with a greater number of patients requiring ICU admission for support managing complications of their malignancy, it's therapy, or conditions unrelated to their underlying cancer. Despite these indications, the presence of a cancer diagnosis has been a common reason for refusal of ICU admission, or admission with treatment limitations.

This session will present the current epidemiology, characteristics and outcomes of patients admitted to Australian and New Zealand Intensive Care Units with cancer, and will describe the change in these outcomes across the last 17 years. Results will be reported for the most common malignancies admitted to ANZ intensive care units, common treatments and complications of malignancy will be reviewed and an agenda for further outcomes research in ICU malignancy will be proposed, with demonstration of early work in the analysis of outcomes relating to specific types of malignancy.

There have been significant developments in the diagnosis and management of ischaemic stroke.

This started with trials showing a benefit for decompressive craniectomy after a malignant hemispheric stroke in patients under 60 undergoing surgery within 48 hours.

The evolution of CT and MRI have enabled us to better image not only the ischaemic core of the stroke, but also the surrounding hypo-perfused brain at risk of ischaemic death; the penumbra. CT and MR angiography now allow rapid, non-invasive detection of occlusions in the major neck and intracranial arterial vessels.

These techniques are key to the appropriate selection of patients for therapeutic interventions aiming at rapid and effective arterial recanalisation to restore blood flow. Intravenous thrombolysis with rt-PA is effective if given early and no later than 4.5 hours. The benefit of intravenous thrombolysis for patients with severe stroke due to large artery occlusion is limited but these patients may be candidates for mechanical thrombectomy. Since 2014, several trials have confirmed the effectiveness of thrombectomy for patients with anterior circulation artery occlusion with a number needed to treat of less than 3 for improved functional outcome. Two recent trials have also shown that in selected patients, the benefit of thrombectomy extends to at least 24 hours, increasing the number of patients eligible to receive this treatment.

The rate of intravenous thrombolysis remains low in many Australian centres, especially in regional areas and only a few metropolitan centres provide a thrombectomy service. With the recent expansion of the time window, the logistics of patients being transferred to these centers has improved but good selection of patients with advanced imaging is a prerequisite to ensure that health resources are used efficiently.

There is a need to improve health services to better manage stroke patients in Australia and worldwide. This has the potential to improve outcome for stroke victims.

People living with HIV in 2018 now have normal life expectancy if receiving Anti-Retroviral Therapy (ART) and often require only one co-formulated pill every day to remain well. However there are still people living with HIV who are unaware of their diagnosis; who may present with a critical illness. Knowing who to test is essential. The population living with HIV are also ageing and often have comorbidities. It is vital that clinical conditions associated with HIV are recognised and for those receiving ART that significant drug-drug interactions are avoided. Pre Exposure prophylaxis (PREP) is widely used to prevent transmission and when to consider post exposure prophylaxis (PEP) should be understood. Although only one person has been cured of HIV ongoing research continues.

Hepatitis C treatment has been revolutionised with Direct Acting Antiretrovirals (DAAs) that are taken in an outpatient settings, however treatment rates in Australia are in decline. Patients living with Hepatitis C need to be identified to be treated. Those patients with established severe liver disease may remain at risk of decompensation and therefore it is considered vital to ensure linkage into adequate follow up. Drug interactions are important to recognise in patients completing DAAs and although Hepatitis C can be cured the management of any coinfections with blood borne viruses requires careful attention.

Blood Pressure (BP) is one of the vital hemodynamic parameters that we often aim to optimize for critically ill patients. Our decisions regarding BP targets, and ensuing use (or avoidance) of vasopressor agents, may directly impact on outcomes for these patients. Despite being a fundamental tenet of critical care, there is a lack of quality evidence to suggest optimal BP targets or to guide the use of vasopressors for individual patients with shock. A mean arterial BP (MAP) of 65-70 mmHg is an often-cited initial BP target for patients during vasopressor therapy. Use of vasopressors to maintain MAP of 65 mmHg or greater remains one of the core clinical criteria in the new definition of septic shock. However, such standard targets are unlikely to be applicable to all patients, many of whom would have a basal MAP higher than 65-70 mmHg, often to a varying degree, during their usual pre-illness state. Therefore, a vasopressor therapy guided by standard BP thresholds may result in a variable degree of untreated relative hypotension, which is associated with new-onset acute kidney injury (AKI). From a physiological standpoint, any relative reduction in net perfusion pressure across an organ's vasculature can overwhelm its autoregulatory mechanisms, which are already under stress during a shock state. In a recent major RCT, among patients with chronic hypertension, targeting a higher MAP of 80-85 mmHg, versus 65-70 mmHg, showed a lower incidence of subsequent AKI, but with no difference in mortality. However, this RCT did not take patients' pre-illness basal BP into account, making it difficult to extrapolate these results to those patients with chronic hypertension, who usually have a well-controlled basal BP, or to those patients, who although have a higher-than-normal basal BP but are not formally diagnosed with hypertension. Accounting for a patient's pre-illness basal BP can minimize variation in the degree of untreated relative hypotension that is often inadvertently accepted in conventional care. It is a simple, but untested, strategy. Further, new tools that can monitor cerebral autoregulation in real-time are on the horizon and have shown some promise in suggesting an optimal BP for individual patients with shock. This technology can further help adjust the initial BP target as a patient deteriorates or recovers from the shock state.

Recently, several novel glucose-lowering targets have had drugs developed. This has resulted in several new drugs that have been approved for the local market to treat hyperglycaemia in patients with type 2 diabetes.

This presentation will attempt to provide:

1. A concise summary of these drugs for an Intensive Care Physician.
2. A pragmatic framework for what the non-Endocrinology Doctor should do with these drugs whilst the patient is in, and being discharged from, the Intensive Care Unit.
3. An outline of current trials evaluating glycaemia in the Intensive Care Unit.

Frailty is a state of reduced physical, physiological and cognitive reserve. Tools to measure frailty which were developed in geriatric medicine practice, have over recent years been applied to patients admitted to the Intensive Care Unit (ICU). Studies in the ICU suggest that frailty is associated with reduced reduced likelihood of discharge home and reduced survival at one year. Survivors also report lower quality of life measures on both physical and mental assessments. The most common of frailty assessment tool used in the ICU, is the Clinical Frailty Scale which has also been recently adopted by The Australian and New Zealand Intensive Care Society (ANZICS) as part of routine data collection on all ICU admissions. Last year, for the first time 39 sites submitted data about frailty on over 10,000 ICU admissions. Frail patients were more commonly older women admitted with medical diagnoses. Even after adjusting for age, medical co-morbidities and acute severity of illness, frailty was an independent predictor of mortality.

This presentation will outline current Choosing Wisely projects happening in ICUs around Australia. It will also discuss the Choosing Wisely Australia campaign and its direction.

Lung Recruitment in ARDS - To be or not to be by Dr Swapnil Pawar