CCC Update 013
Welcome to the the 13th CCC Update!
I met Marcelo Amato in 2014 and was super-impressed; he’s a great speaker and a profound thinker when it comes to mechanical ventilation and ARDS. He was the lead author of a 2015 NEJM paper suggesting that ‘driving pressure’ might be the key ventilatory variable to optimise to prevent ventilator-induced lung injury in patients with ARDS. This page, coauthored by the equally impressive Jack Iwashyna (@iwashyna), explains the concept of driving pressure and the rationale for its use, including a summary of the Amato et al 2015 article. More studies needed of course…
Pulseless Electrical Activity (PEA)
We are all down with the ALS approach to asystole/PEA… However, there are at least 2 problems with this. The ‘Hs and Ts’ approach is clunky and there is the spectre of Pseudo-PEA. In an age of ‘Echo for everyone’ we are realising that PEA is a very heterogenous condition. Some PEA patients are simply severe shock patients that might not even need CPR and with appropriate treatments these ‘mostly dead’ patients may do much better than the other ‘completely dead’ PEA/asystole patients. Read on for all the ins and outs.
Open chest management and delayed sternal closure
If a patient arrives in the ICU after cardiac surgery with an open chest, your antennae should start twitching — you most likely have a very very sick patient in your midst. Read this page for the rationale, indications and pros and cons of delayed sternal closure in the critically ill post-cardiac surgery patient.
After the Sepsis SMACCDOWN in Chicago, many were left wondering if they have any idea what sepsis actually is… never mind how to treat it. In reality, we know what a septic patient is, someone who is properly sick from an infection that has triggered off a deleterious host response. The problem is, current definitions – promoted by the Surviving Sepsis Campaign Guidelines — don’t necessarily reflect this and over-complicate matters. This page gives the current key definitions related to sepsis and highlights the problems with SIRS-based definitions, as well as problems with diagnosing sepsis in general. It also provides a summary of the Kaukonnen et al NEJM 2015 article (et al includes two of my colleagues from the Alfred, Dave Pilcher and Jamie Cooper 😉 ) that debunks the utility of the SIRS critieria in the Australasian ICU population. I also preview the soon-to-be-published “Sepsis 3.0” definition… yes, I will have to update this page again soon! Wouldn’t it be good if there was decent sepsis biomarker we could use?
Don’t hold your breath in anticipation of biomarkers clearing the muddied sepsis waters. This page provides an overview of the different types, highlights some of the more commonly discussed examples and emphasises the generic limitation shared by all current sepsis biomarkers. With nearly 200 sepsis biomarkers in the published medical literature, you’d think it at least one would cut the mustard…
Some would argue that procalcitonin is the sepsis biomarker that comes closest to lacerating hot-tasting yellowish condiments. Procalcitonin was de riguer in other places I’ve worked, but I don’t use it these days. This page reviews the biology of procalcitonin (synthesis, kinetics and functions) and the pros and cons of its use as a sepsis biomarker. There is also a summary of key evidence, namely the 2010 PRORATA study and a systematic review and meta-analysis from 2015. I also provide a summary of how I might use procalcitonin if I was going to use it… (?!?)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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