Discover and read the best of Twitter Threads about #CCSSA2022
Most recents (24)
Last for this session is Prof Sean Chetty @seanC001 speaking on 'To Sedate or Not to Sedate'. Is this a ?that is the question? scenario...
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. In modern ICU practice, the modern concept is analgosedation, but this needs to be teased apart a little.
#CCSSA2022
#CCSSA2022
The typical modern ICU patient is older, sicker and more complex than ever before. Pain is generally a root cause of distress for many patients, but there can be others - dyspnea, delirium and sleep deprivation.
#CCSSA2022
#CCSSA2022
Next up is Prof Joao Batista Borges, speaking on "Individualised lung recruitment to minimise VILI - the 'Teen Lung' Concept"
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
To understand recruitment manoeuvres, we need to have a clear understanding of regional lung mechanics, and the concepts of collapse and hyper-distension, along with the lung hysteresis curves.
#CCSSA2022
#CCSSA2022
The 'teen lung' concept is the idea of a lung that is stretched and overdistended, where there is inadequate or insufficient lung recruitement. It is 'partial recruitment' and may be worse than no recruitment at all.
doi.org/10.1186/s13054…
#CCSSA2022
doi.org/10.1186/s13054…
#CCSSA2022
Next is Giancamo Bellani, talking on 'Relationships between oxygenations indices & patient outcomes'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Several indices have been proposed as bedside 'markers' for the development of VILI. They are relevant as they allow us to prognosticate patients, and therefore to determine the need for a higher level of intervention (e.g. ECMO).
#CCSSA2022
#CCSSA2022
PF ratio remains a very robust predictor of mortality, and is the crux for the diagnosis of ARDS.
#CCSSA2022
#CCSSA2022
Next up is respiratory therapist Benevides Netto on 'Optimising Patient Ventilatory Interactions'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
First speaks to how patient-ventilator dyssynchrony is common, and has been found in all modes of ventilation! It has significant consequences, via a variety of mechanisms - see P-SILI (but not only P-SILI!)
How to monitor asynchrony
- Graphic analysis
- Oesophageal pressure
- Diaphragmatic ultrasound
- Electrical impedence tomography
#CCSSA2022
- Graphic analysis
- Oesophageal pressure
- Diaphragmatic ultrasound
- Electrical impedence tomography
#CCSSA2022
Next up is (my office-mate - yes I'm showing off) Dr Susan Murphy @susan_icu talking about 'Preventing Intubation'.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
So how can we divide patients in whom we want to prevent intubation
- Those we want to prevent primarily intubating (e.g. a patient with acute hypoxaemic respiratory failure)
- THose who were previously intubated who you want to avoid re-intubating
#CCSSA2022
- Those we want to prevent primarily intubating (e.g. a patient with acute hypoxaemic respiratory failure)
- THose who were previously intubated who you want to avoid re-intubating
#CCSSA2022
Often to try prevent intubation, we consider alternative types of respiratory support, which include:
- Simple Oxygen Delivery
- High Flow Humidified Oxygen
- Non-Invasive Ventilation
- Continuous Positive Airway Pressure
#CCSSA2022
- Simple Oxygen Delivery
- High Flow Humidified Oxygen
- Non-Invasive Ventilation
- Continuous Positive Airway Pressure
#CCSSA2022
One of two morning sessions (this one themed 'Take a Breath') at CCSSA2022 - starting with a talk by Prof Charles Feldman on 'E-cigarettes, vaping and lung injury'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Prof starts by saying that vaping is not the panacea that it was hoped.
Electronic cigarettes (e-cigarettes or vapes) work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain nicotine, THC, CBD, flavourants etc...
#CCSSA2022
Electronic cigarettes (e-cigarettes or vapes) work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain nicotine, THC, CBD, flavourants etc...
#CCSSA2022
Interesting that many of the THC-containing preparation contain Vitamin E - which when injected or ingested is safe, but when inhaled as an aerosol may have a deleterious effect
doi.org/10.1016/j.amjm…
#CCSSA2022
doi.org/10.1016/j.amjm…
#CCSSA2022
Final paeds session is by Prof Brenda Morrow on 'Sleep - the Final Frontier'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Sleep is critical to normal health, and children need much more sleep than adults. Circadian rhythms are established as early as two months of age.
doi.org/10.1038/497S2a
doi.org/10.2147/NSS.S6…
#CCSSA2022
doi.org/10.1038/497S2a
doi.org/10.2147/NSS.S6…
#CCSSA2022
Sleep deprivation in healthy children has clear deleterious acute and long term effects.
#CCSSA2022
#CCSSA2022
A quick run to the rest of the paeds session, where Tarryn Forsyth @TaForsyth is speaking on 'Post Abdominal Surgery - is TPN still necessary?' in paediatrics
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
The crucial trial in this space is the PEPaNIC trial, from 2016 in the NEJM.
doi.org/10.1056/NEJMoa…
#CCSSA2022
doi.org/10.1056/NEJMoa…
#CCSSA2022
Screening is essential as this may identify patients who need early nutritional supplementation.
Paediatric Methods - PNST, STRONGkids Screening Tool, STAMP. but none validated in the critically ill subpopulation.
#CCSSA2022
Paediatric Methods - PNST, STRONGkids Screening Tool, STAMP. but none validated in the critically ill subpopulation.
#CCSSA2022
Last in the session if Prof Veronia Ueckerman, with a talk entitled - Thiamine, what is all the W(h)ining About?
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Thiamine is a water-soluble vitamin essential for carbohydrate metabolism. It is a cofactor for four enzymes used in ATP production. It has limited storage in the human body, and is absorbed in the small intestine.
#CCSSA2022
#CCSSA2022
Risk factors for thiamine deficiency include
- Malnutrition
- Chronic alcohol consumption
- Pregnancy (due to increased requirements)
- Excess renal losses (chronic diuretic therapy)
- Obesity pre-bariatric surgery and post surgery
#CCSSA2022
- Malnutrition
- Chronic alcohol consumption
- Pregnancy (due to increased requirements)
- Excess renal losses (chronic diuretic therapy)
- Obesity pre-bariatric surgery and post surgery
#CCSSA2022
Next up is Lance Michell, who is giving a talk entitled 'Freshly squeezed - How should Vit C be served in ICU?'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Vit C is famous for having curing scurvy back in the 1700s, but also for Paul Marik's controversial claim of its efficacy for sepsis in a paper in 2017, as part of a coctail of hydrocortisone, thiamine and Vit C.
doi.org/10.1016/j.ches…
#CCSSA2022
doi.org/10.1016/j.ches…
#CCSSA2022
The activity of Vit C in the body includes activity as an antioxidant, helping reduce inflammation.
#CCSSA2022
#CCSSA2022
During the afternoon session on nutrition, Dr Nadiya Ahmed will be speaking about 'Hitting the nail on the head, iron supplementation in the ICU'.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Iron has many functions including O2 delivery, in myoglobin (O2 storage in muscles) and metabolism (cytochromes). Iron metabolism in critical
doi.org/10.1186/cc9992
#CCSSA2022
doi.org/10.1186/cc9992
#CCSSA2022
Oral formulations have systemic side effects (GI side effects) whilst older IV formulations have a risk of anaphylaxis.
#CCSSA2022
#CCSSA2022
Last up for this renal session if Prof Shahed Omar from CHBAH - 'Beyond the Renal Failure'.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
His interest evolved from a problem we have in SA - a high burden of organophosphate toxicity. In our unit in Soweto, about 15-20% of our admissions are from organophosphate intoxication!
doi.org/10.1016/j.afje…
#CCSSA2022
doi.org/10.1016/j.afje…
#CCSSA2022
There is limited access to oximes in SA, and their application in these OPP intoxication is not great, probably because of the different types of organophosphates our population is exposed to!
doi.org/10.1177/031005….
#CCSSA2022
doi.org/10.1177/031005….
#CCSSA2022
Next is Dr Gavin Joynt on 'CRRT in ICU - Individualised Antibiotic Dosing'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Appropriate blood and tissue concentrations of antibiotics is important, particularly in critically ill patients!
#CCSSA2022
#CCSSA2022
Trough concentrations in ICU patients on RRT show a failure in reaching the target in 26-72% of cases! See the SMARRT study from 2021 and DALI study in 2014.
doi.org/10.1093/cid/ci…
doi.org/10.1093/cid/ci…
#CCSSA2022
doi.org/10.1093/cid/ci…
doi.org/10.1093/cid/ci…
#CCSSA2022
These patients are at high risk of malnutrition - fluid limitations, disturbances in electrolytes, CHO metabolism alterations, loss of protein and energy stores, frailty, etc...
#CCSSA2022
#CCSSA2022
All based on ESPEN guidelines from 2021. This is a critical resource!
doi.org/10.1016/j.clnu…
#CCSSA2022
doi.org/10.1016/j.clnu…
#CCSSA2022
Next up is renal clinical technologist Marissa Coetzee on 'Renal Replacement Modalities - 3 vs 12 vs 24h - A Carer's Perspective'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Starts with an overview of the available therapies (with one-two examples of each but some have lots more).
Intermittent - IHD
Continous - CVVD, CVVHD
Hybrid - SLED
Peritoneal - CAPD, APD
#CCSSA2022
Intermittent - IHD
Continous - CVVD, CVVHD
Hybrid - SLED
Peritoneal - CAPD, APD
#CCSSA2022
But what are the carer's concerns:
- Safety and efficacy of treatment
- Mobility and availability of the patient for other interventions
- Infection control risks
- Physical exertion of performing the critical taks (lifting bags etc...)
...
- Safety and efficacy of treatment
- Mobility and availability of the patient for other interventions
- Infection control risks
- Physical exertion of performing the critical taks (lifting bags etc...)
...
Next is Dr Busi Mrara, who unfortunately couldn't make it, but managed to record the talk and sent it to us. She will be talking about 'Augmented Renal Clearance'
#CCSSA2022 #FOAMcc #critcare
#CCSSA2022 #FOAMcc #critcare
ARC in sepsis was first described as early as 2008, and is defined as CrCl >130ml/min/1.73m2 based on a timed urine creatinine clearance.
It was compared to early kidney disease in diabetics. It was also described
doi.org/10.1177/031005…
It was compared to early kidney disease in diabetics. It was also described
doi.org/10.1177/031005…
Another proposed definition is 10% above upper limit of normal (GFR>160ml/min/1.73m2 in men and >150ml/kg/1.73m2 in women) by the australian group headed by Bara alumnus Prof Jeff Lipman. #CCSSA2022
Mid-morning session I've gone to the renal session - starting with Dr Nadiya Ahmed on 'Who Will Develop AKI?'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
1 in 5 patients will develop AKI, we need to know who these patients are, and who will need support. There are non-modifiable RFs (e.g. age) and modifiable RFs (e.g. sepsis, ischaemia toxins), but these are difficult to use at the bedside.
doi.org/10.1186/s12882…
@CCSSA2022
doi.org/10.1186/s12882…
@CCSSA2022
The definition of AKI has evolved from RIFLE to KDIGO (via AKIN), but this allows us to identify patients who already HAVE developed AKI. What we need to be able to do is identify patients at an early stage of injury, or ideally those at risk of injury? #CCSSA2022
Last session during the plenary, the current president of the CCSSA, Prof Fathima Paruk @FParuk_CritCare on how AI will transform critical care.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
There are different types of AI
Weak AI - an AI-based algorithm that offers suggestions based on previous choices - think Netflix offering suggestions of series or movies.
@CCSSA2022
Weak AI - an AI-based algorithm that offers suggestions based on previous choices - think Netflix offering suggestions of series or movies.
@CCSSA2022
Strong AI - this is the type of AI probably to be used in ICU, where it integrates complex data and makes some decisions, preferably with some human oversight and input. Integrated closed loop haemodynamic support would be an ICU application.
#CCSSA2022
#CCSSA2022
Next is Prof Heleen van Aswegen, talking about 'The complex interplay between psychology and physiotherapy'.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
The critically ill patient is at high risk of psychological distress - there is uncertainty, pain, a noisy environment. Functional limitations and physical illness can have detrimental effects on feelings of self-worth as well.
#CCSSA2022
#CCSSA2022
Psychological distress has a negative impact on the adherence to rehabilitation, and patients with distress are likely to have a prolonged length of stay and pain. #CCSSA2022
Next up is Prof Mette Berger - 'Small Things Matter - The Importance of Micronutrients'
I love these talks, because there is such a personal knowledge gap, I always feel like I learn so much!
#CCSSA2022 #critcare #FOAMcc
I love these talks, because there is such a personal knowledge gap, I always feel like I learn so much!
#CCSSA2022 #critcare #FOAMcc
What micronutrients are important? Its the ESSENTIAL MICRONUTRIENTS that we need to worry about. They are critical for numerous aspects of critical care, including wound healing and immunity.
A great review - doi.org/10.3390/nu1201…
#CCSSA2022
A great review - doi.org/10.3390/nu1201…
#CCSSA2022
Prof Berger's interest in micronutrients started decades ago, when she assessed the micronutrient losses in burns patients from burns exudates - massive losses of zinc, copper & selenium - this work to led to the modern paradigm of supplementing these in burns ICUs.
#CCSSA2022
#CCSSA2022
First weekend lenary session at CCSSA 2022, chaired by @BranniganLliam and Prof M Mer. Starting with a talk by Dr Francesca Rubulotta @frubulotta on 'Knowledge Transfer Across the World' - appropriately a recorded talk made half way around the world! #CCSSA2022 #critcare #FOAMcc
Incidentally I met Dr Rubulotta a few years ago at a different congress - the amazing ventilation congress Ventilation Through the Ages - what a wonderful, passionate intensivist. I'm gonna plug the next one here, which will be next year!
#CCSSA2022 #VTA23
#CCSSA2022 #VTA23
Dr Rubulotta starts by explaining 'Knowledge Transfer' as a mechanism to close the know-do gap. It is the synthesis, exchange and application of knowledge by relevant stakeholders in order to accelerate the benefits of global and local innovation. #CCSSA2022
Next is Dr Bilal Bobat, a hepatologist (also at WDGMC) talking about 'Immunosuppressive Therapy for Transplant'.
@bilalbobat
#CCSSA2022 #FOAMcc #critcare
@bilalbobat
#CCSSA2022 #FOAMcc #critcare
Azathioprine in the 1950's and 60's and then cyclosporine in the 1980's revolutionised transplant immunosuppression. Most recently, Tacrolimus (especially prolonged release preparations) has become very popular due to great efficacy. #CCSSA2022
5 year survival is best for kidney transplant patients, and worst for lung transplant patients. All survival rates are improving over time however, in no small part due to improved immunosuppression regimens.
#CCSSA2022
#CCSSA2022
Next is Tanna Michel, a registered dietician, who will speak on 'Perioperative Nutrition in Transplant Patients', talking specifically about liver transplant patients.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
This patient cohort has a very high rate of malnutrition, as a result of a hypercatabolic status, decreased nutrient absorption and decreased caloric intake. There is a resulting negative energy balance.
10.3390/nu9101126
10.3748/wjg.v22.i4.1513
#CCSSA2022
10.3390/nu9101126
10.3748/wjg.v22.i4.1513
#CCSSA2022
Malnutrition and sarcopaenia are related to negative outcomes, hence timely nutritional assessment and advice needs to be incorporated to their care preop, periop, and postop.
#CCSSA2022
#CCSSA2022
In the afternoon session on Liver Transplantation, the first talk is by Dr Lliam Brannigan @BranniganLliam, the head of the Transplant Critical Care Unit at Wits Donald Gordan Medical Centre.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
The global and local burden of liver disease is substantial, as a result of alcholic and viral liver disease. There are huge barriers to access to liver transplantation in Africa.
10.1111/liv.12884
#CCSSA2022
10.1111/liv.12884
#CCSSA2022
The programme at WDGMC has grown over the years, and the COVID pandemic has caused in shift, with an increase in the relative proportion of transplant cases that are the result of related living donors (as opposed to cadaveric donors).
#CCSSA2022
#CCSSA2022
