Modernizing Critical Care Teaching: Evidence-Based Transition from Traditional Methods, Slides of Biomedical Engineering

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Evidence-based critical care – Update 2006 Docsity.com Intensivist shortage  Experts predict that as the US population ages, the shortage of intensivists will become increasingly acute  By 2020, the supply of intensivists will meet only 22% of the demand for their services Docsity.com The old way…”Why do you do it that way??”  “Well, I learned this from Dr. X”  “We’ve always done it this way”  “We have good outcomes”  “I have an article to prove it” (more on this later…) Docsity.com The old way… dopamine Dopamine in low doses activates dopamine receptors in the kidney Renal blood flow is increased Urine output is increased (sometimes)  The assumption, and teaching, became… Docsity.com The old way… dopamine Dopamine is indicated for: Preventing renal failure Treating renal failure Reversing renal vasoconstriction when vasopressors are used Preventing renal failure during aortic and renal cross-clamping Dopamine flowed like water (often better than urine) in ICUs worldwide Docsity.com Evidence-based concepts  The best study is: Prospective Randomized Double Blinded – not always possible Multicenter Meta-analyses evaluate a number of similar studies Docsity.com Evidence-based concepts  Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock  11 critical care societies - international  Initial document: CCM March, 2004  Evidence-based review: CCM supplement November, 2004 Docsity.com Grading system Grade A: At least 2 large, randomized trials with clearcut results Grade B: At least 1 large, randomized trial with clearcut results Grade C: Small, randomized trials, uncertain results Docsity.com Low tidal volume strategy  Barotrauma  High pressure generated with flow of air into lungs  Volume trauma (volutrauma)  Overdistention of alveoli can lead to further lung damage Docsity.com Low tidal volume strategy Classic practice: Vt 10-15 cc/kg Hypothesis: lower Vt is protective of alveolar damage and outcome in ARDS  ARDS-net trial, NEJM, 2000 Comparison of 6 ml/kg vs 12 ml/kg  861/1000 patients Mortality 31% vs 39.8% Reduction in mortality of 22% Docsity.com Low tidal volume strategy When ARDS diagnosed, adjust Vt for ideal body weight  60 kg x .6 cc/kg = 360 cc  pCO2 will likely increase – permissive hypercapnea GRADE B Docsity.com Steroids for “late” ARDS  ARDS-net randomized placebo- controlled trial Goal 200 patients over 6-8 years No value in use of steroids in “late” ARDS Docsity.com Other ARDS modalities We no longer consider: Prone position Inhaled nitric oxide Surfactant Liquid ventilation Docsity.com Evidence-based critical care Glucose control in critically ill patients Docsity.com Intensive insulin therapy Mayo Clin Proc, 2004  800 critically ill medical-surgical patients in a community ICU Hospital mortality decreased Decreased ICU LOS, ARF, transfusion requirement Most benefit in septic patients Docsity.com Intensive insulin therapy GRADE D based on original study, (randomized but single center, mainly surgical patients), likely upgrade to C German study (600 patients) – negative  Two large scale randomized trials underway  European study – 3500 medical/surgical patients  Australia/NZ – 4500 medical/surgical patients Docsity.com a | | Evidence-based critical care Activated protein-C in sepsis (Xigris) Docsity.com RH Activated Protein C  Prowess Study  Recombinant human activated protein C worldwide evaluation in severe sepsis  Randomized, double blinded, placebo controlled  96 hour infusion of activated protein C (APC)  Endpoint: death at 28 days Docsity.com RH Activated Protein C  Prowess study  1690 patients (840 placebo; 850 APC)  Mortality 30% vs 24.7%, p=0.005  6.1% reduction of death  Serious bleeding 2% vs 3.5%, p=0.06  Similar number of blood transfusions Docsity.com RH Activated Protein C  Prowess study  The difference in outcome was greatest in patients with an APACHE score >25  Address study  PRCT of RHAPC in patients with APACHE <25  No improvement in outcome  May be worse outcome in SURGICAL patients with single organ dysfunction Docsity.com a | | Evidence-based critical care CORTICOSTEROIDS AND SEPTIC SHOCK Docsity.com Corticosteroids and sepsis Old teaching: don’t give septic patients high dose steroids New thought: patients with septic shock who are unresponsive to pressor agents may have adrenal insufficiency Docsity.com Corticosteroids and sepsis  Incidence of adrenal insufficiency  30-50% in critically ill patients  50-60% in patients with septic shock Clinical presentation  resistant hypotension  hyponatremia, hyperkalemia  Low or “normal” serum cortisol level Docsity.com Corticosteroids and sepsis  Should low doses of corticosteroids be used in the treatment of septic shock? GRADE C  SSC guidelines suggest steroids in pressor-dependent patients with low serum cortisol (don’t even bother with the cortrosyn stimulation) Docsity.com Evidence-based critical care PULMONARY ARTERY CATHETER USE IN THE ICU Docsity.com PA catheter use in the ICU Old practice: any unstable patient who didn’t respond to fluids or who had possible cardiac dysfunction; “we didn’t know where we were…”  Preoperative “optimization” of high risk patients Old practices questioned: Connors, et al, JAMA, 1996  Editorial: “abandon PACs until PRCT” Docsity.com a | | Evidence-based critical care EARLY GOAL-DIRECTED THERAPY IN SEPSIS Docsity.com Early goal-directed therapy  “Standard” goals for sepsis (resuscitation)  MAP >65  CVP 8-12  Urine output >0.5 cc/hr Docsity.com Early goal-directed therapy DO2 = Hgb (SaO2) x 1.34 x CI x 10  “Supranormal” goals for PAC (1980s)  CI > 4.5 L/min/m2  DO2I > 600 ml O2/min/m 2  VO2I > 170 ml 02/min/m 2  Fluids, blood, inotropes, pressors… We could measure our progress with a calculator!! Docsity.com Early goal-directed therapy  There IS value to optimizing cardiac output, oxygen delivery and SVO2 if you intervene early enough  (Is it really the SVO2 that makes the difference, or is it resuscitation??) Docsity.com Evidence-based critical care ANTIBIOTICS and INFECTION CONTROL WHO NEEDS TREATMENT AND FOR HOW LONG VENTILATOR ASSOCIATED PNEUMONIA CATHETER-RELATED BACTERIAL STREAM INFECTION C-DIFFICILE COLITIS Docsity.com Who needs antibiotics?  Systemic inflammatory response syndrome (SIRS)  Fever means inflammation, not necessarily infection  Emergence of multiresistant bacteria  Treating fever alone or fever + WBC without a source of infection is usually not in the best interest of the patient Docsity.com a | | Evidence-based critical care VENTILATOR-ASSOCIATED PNEUMONIA DIAGNOSIS isl A0n ine PREVENTION Docsity.com Ventilator-associated pneumonia - diagnosis Classic teaching: Fever, WBC, purulent sputum, + culture, infiltrate  75% of intubated patients are colonized with GNB after 3 days in the ICU  You could have bronchitis or sinusitis + atelectasis, or pulmonary edema  Endotracheal aspirate vs BAL  BAL samples give quantitative cultures Docsity.com Ventilator-associated pneumonia - diagnosis  Fever/WBC, + culture without purulent sputum or CXR – NO ANTIBIOTICS  Fever/WBC, purulent sputum or changing CXR, + sputum culture → empiric therapy  Fever/WBC, purulent sputum or changing CXR, + sputum culture → BAL + empiric therapy Docsity.com Ventilator-associated pneumonia What is known  More likely from mouth contents than from regurgitation of stomach contents  Head of bed 30 degrees up is the only proven preventive technique!!  Early effective antibiotic therapy is essential !!  Start with broad-spectrum coverage, then taper antibiotics based on EA/BAL results Docsity.com Catheter-related BSI  Prevention – what doesn’t work  Changing lines every three days  Performing wire changes  Putting antibiotic solutions (goop) on the site  Antibiotic lock solutions Docsity.com Catheter-related BSI  Prevention – what DOES work  Subclavian site  Prep: Chlorhexidine (not povidone)  Barrier precautions: Hat, mask, gown, gloves, FULL body drape  Antiseptic coated catheters ($$$; beware of hospital administrators)  Management of stopcocks: alcohol prior to injections, keep ports closed Docsity.com Infection control techniques We all have the power to limit the occurrence of hospital acquired infections Hand washing is the most effective method of limiting hospital acquired infections Docsity.com Infection control techniques  Soap and water Hand disinfectant solutions : Steris product, Purell Remember: C-difficile toxin spores are not killed by hand solutions; use soap and water Wear protective gowns and mask when examining c-diff patients Docsity.com | EBM in perspective Docsity.com EBM in perspective We have good data (B) that will probably never get better despite further studies  Crystalloids vs colloids, albumin  Bicarbonate in acidosis We are able to eliminate unproven or potentially unsafe practices  NO for ARDS  Prone positioning for ARDS Docsity.com EBM in perspective We practice with lots of E’s – these probably can’t ethically be studied  Use of antibiotics early in sepsis  Draining abscesses  Giving fluids for hypovolemia  Vasopressors in septic shock  Mechanical ventilation in respiratory failure Docsity.com EBM in perspective – the good We know the quality of the data Development of consensus statements  ASA, SCCM, ACCP, EAST  www.guideline.gov Guidelines and protocols  Keep us current and consistent in our care  Allows ongoing monitoring of practices  Educate our trainees Docsity.com EBM in perspective: the bad  There are patients with low urine output or impending renal failure secondary to low cardiac output who may benefit from the use of low dose dopamine Docsity.com EBM in perspective – the scary OUTCOMES RELATED TO EVIDENCE- BASED CARE WILL BE MONITORED AND WILL BECOME A MEASURE OF QUALITY AND POTENTIALLY A SOURCE OF MEDICOLEGAL LIABILITY Docsity.com EBM in perspective – keep reading  The data may change !!  JAMA, July 13, 2005 Contradicted findings (16%)  Hormone therapy and CAD risk  Vitamin E and CAD risk  Vit A and breast cancer  Monoclonal AB to endotoxin (HA1A)  Nitric oxide in ARDS Docsity.com Summary We should use EBM consensus statements to keep our knowledge current Reaching the highest rankings (grade A) may be limited by ethics, resource restrictions and marketing strategies  Be watchful for “new” data or negation of previously accepted data Docsity.com Summary Realize that the public is watching our adherence to practice guidelines  Accept the fact that external monitoring of evidence-based practices and outcomes will be standard in the future  Be proactive in maintaining high standards of care Docsity.com