Recent controversies in sepsis

Below is a recent talk I prepared for a teaching meeting for the ICU and ED staff. Unfortunately I was still on my train when I was due to give it so here it is online instead.


References:

  • Annane D. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013 Nov 6;310(17):1809.
  • Brown SGA. Fluid resuscitation for people with sepsis. BMJ (Clinical research ed). BMJ Publishing Group Ltd; 2014 Jul 22;349(jul22 16):g4611–1.
  • SMACC Podcast: Myburgh: Fluid Resuscitation: Which, When and How Much?
  • EMCrit Podcast: Marik: Fluids in Sepsis
  • EMCrit Podcast: Angus on Process
  • Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. Review. PubMedPMID: 18628220.
  • Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. 2014 Jun 24;:1–9. [free pdf]
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368–77.
  • Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010 Feb 24;303(8):739–46.
  • Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee2012. Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PubMed PMID: 23353941.
  • The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18;:140325070040003.
  • Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA. American Medical Association; 2014 Apr 2;311(13):1308–16.

EMS Gathering Review

It’s been a month since the Irish EMS Gathering conference that I had the pleasure of speaking at. This was the second year and it’s a pretty unique event. It’s main focus is naturally pre hospital care and it’s great to see a medical conference that isn’t just doctors talking about how awesome doctors are… Plus, Carley was there so it was nice to catch up.

Here’s just 3 (of many) highlights.

Gareth Davies [London HEMS]

Gareth Davies

Absolutely lovely bloke with brain the size of the a planet and clearly very, very good at what he does. My take home message was his talk on impact brain apnoea. This is a new phenomenon to me and to be fair I think the London HEMS guys have coined the term. It is based on some wonderful rat models from a long time ago though. The basic idea is that the massive trauma of high speed motor vehicle accidents leads to some form of brainstem event that results in transient apnoea and blown pupils. This is associated with a massive surge of catecholamines and resultant cardiovascular instability and collapse. You only see this if you do prehospital care, and even more so if you’re a doc on the scene of something like the Isle of Man TT or the North West 2oo, both designed to allow young crazy, northern irish men try to kill themselves in as dramatic a way as possible. The key, Davies says, is early intervention not nihilism. The reason these guys do so badly is not because of the their structural brain injury but from prolonged prehospital apnoea. Davies, like the wonderful Mark Wilson advocates that if these guys are oxygenated early then they need aggressive neurosurgical intervention and never mind the blown pupils. The poor outcomes that people quote are self-fulfilling prophecies – if you do not intervene then it’s no surprise they do poorly.

He always goes down in history for his nuanced critique of the PK format of talks as Pokemon talks.

[Impact Brain Apnoea also here on Resus.ME]

The ATACC guys

ATACC

I made the mistake of not going to their simulation workshop but chatting to Mark Forrest and Jason you get an idea of how much these guys are passionate about improving prehospital trauma care. They have made the ATACC manual available as a FOAMed resource and I’m about half way through and loving it so far. Alan Watts, one of my fellow trainees and FOAMed connoisseur told me it was the best course he’s ever been on so it’s on my wish list.

Conor Deasy and the Trauma audit

Conor Deasy

To me Conor Deasy was always the lead singer in this band but turns out he’s a researcher, EM consultant and now the trauma audit lead for Ireland

I’ve bemoaned our lack of a functional trauma system in Ireland on twitter before but I suppose it’s worth mentioning again. We only have one hospital in the country with all the requisite specialties but as Karim Brohi has noted, a hospital of specialties is not a specialist hospital. Ireland has a population of less than 5 million. It’s not clear how many trauma centres we might need, but it’s going to be a lot less than the current 28 EDs we have that have the potential to receive major trauma. Trauma remains an inconvenience to hospitals in Ireland. No one is really planned and prepared for it and there is no systems wide approach to making it efficient, effective and seamless. At present we have no data to show that we’re not very good at trauma. Hopefully trauma audit (no matter what issues there may be with TARN) will give us a basis for something like the NCEPOD report that seemed (to me as a very junior doc at the time) a big deal in improving UK trauma care.

(Yet more) reflections on SMACC Gold

Lots of other folk have put their reflections on SMACC Gold online and I’m here to join the crowd.

I missed the first SMACC as purse strings were a little tight. They’re a little tight this year too but I really wasn’t going to miss two SMACCs…

It was great to have an opportunity to come and speak though I’ll confess I was much more comfortable teaching neuroanatomy than being on the airway panel with Levitan, Weingart, John Hinds and Brent May. But it was all good really.

levitan 1

I was very impressed that they chose to devote a 2 hr main area session on end of life issues that incorporated a live integrated twitter discussion.

SonoWars in particular caught my eye as one of the most creative and slickly ran sessions on education I’ve ever seen. Those guys (ultrasoundpod and the sonocave guys) are the best in the business.

The highlight though, without doubt, was the people. This is why you come to SMACC, to meet and be inspired by people. You can throw this off as soft and fluffy and no relevance to medicine but this was the key thing.

smacc gold audience

Ireland has a small EM community and it’s a tough place to do EM. We have a very small number of trained EPs and our departments are crowded, understaffed and morale is frankly pretty low at times. It’s hardly surprising that so many of our trainees or EPs have moved to Oz or New Zealand.

As a result #FOAMed has been an inspiration and an revelation to me. To know the imaginative possibilities of EM out there is what gets me excited about the job. I get to discuss online with some fascinating, interesting and passionate clinicians from whom I can learn. SMACC gold gave me the chance to meet these people in person. And meeting people in person beats twitter hands down.

People who engage in #FOAMed tend to be a little bit off the spectrum in terms of our enthusiasm. We love the medicine, we love to talk about  medicine and we just can’t get enough of talking about medicine so much so that our spouses, our friends and even our medical colleagues get bored of us. SMACC is a conference for all these enthusiastic, excitable little puppies to get together and bond with all the other freaks and geeks.

All these people, the passion, the enthusiasm and the relationships are an inspiration to be a better doctor and a better team member.

So my thanks for SMACC gold are to the people. In particular the committee for being mad enough to invite me and Rob Rogers for being a great roomie – that man rocks!

Here’s some more reflections on SMACC gold so you can check out the love.

I Teach EM

Manu Et Corde

REBEL EM

Injectable Orange

LITFL

Jess

KI Docs

Doug Lynch (with a fascinating set of interview)

Damian Roland

AmboFOAM

Nomadic GP

Bishan

[Let me know if I missed any]

And here’s the opening ceremony

We’ll be in Chicago next year in May 2015 and I for one plan on being there. Be sure and check out the SMACC podcast to catch up on all the talks.

[Images via Oli Flower]

PK Talk for SMACC 2014

Here’s my PK talk for SMACC for 2014. The PK talks for those who can’t remember are short, snappy focused presentations on anything – the SMACC ones are of course focused on critical care.

I presented the same material at our  joint ICU/ED meeting a few days ago so I figured I may as well share it as a PK.


Genuinely intersted as to whether people are aiming for the higher MAPs in SCI. Was news to me and no one in our department was that impressed by it. The studies aren’t wonderful after all.

For those interested here’s last years PK too.

See you at SMACC Gold people!

Respond 2014

I had the pleasure of running a couple of very brief social media workshops at respond 2014 a few days ago. This was the first national conference for community first responders and got off to a great start with more than 300 people.

Community first response was an alien idea to me until a fee months ago. I expected a rather amateurish bunch of enthusiastic civilians but was pleasantly surprised to find a highly motivated and enthusiastic group of volunteers who were well trained under a national structure.  The main aim is of course to provide high quality CPR and early defibrillation as soon as possible in the event of cardiac arrest. Given the often rural nature of Ireland the concept of first responders is valuable.

If you’re in Ireland and interested in more about CFR then check out the conference web page, the hashtag and a few of the local groups.

If you’re here because of the social media workshop looking for more tips  then I suggest you check out this video (aimed at prehospital professionals) and this post.

Congrats to all for a great conference.