Category Archives: Conferences

Notes from 6th East Mids Critical Care and Peri-op medicine conference

Fit for surgery school

Works as long as:

  •  1. patients attend
  • 2. in good time to make a change

Seizures

Check BM and pregnancy status (to r/o eclampsia)

Status epileptics definition:

Status epilepticus is when a seizure lasts longer than 5 minutes or when seizures occur close together and the person doesn’t recover between seizures. Status epilepticus can be convulsive and non-convulsive.

1st line: lorazepam

2nd line 30mg/kg of valoprate or (if CI e.g. pregnant) then levetiracetem then 1g bd. Conveniently they have the same dose

3rd: consider phenytoin, thiopentone

NB thiopentone infusion – causes intravascular movement of K+, so risk of rebound hyperkalaemia. Also WCC and temperature regulation affected so unreliable to use to monitor for infection. May need serial cultures.

CT +/- LP

Check drugs levels, toxicology

Rx of limbic encephalitis: IVIG, plasmaphoresis, corticosteroids

Fever

Normal: 35.6 – 38.2 – diurnal variation. lowest in morning. increases in evening. mean 36.5

cultures it T>= 38.3 (SCCM & IOSA)

Opioid light acute peri-operative pain management

Pre-op counselling, ascertain and manage expectations.

If going to use gabapentin prob need 900-1200mg. Useful for chronic pain/complex patient? Could make very drowsy.

It is possible to do major surgery without opioids.

Dexamethasone – need >= 0.1mg/kg for effect

If using MR oxycodone or morphine then STOP before discharge

An option is clonidine 150mcg made up to 10ml and give 15mcg increments akin to morphine. NB will cause hypotension, so be patient and wait for long enough before giving next dose.

Ketamine. 0.2-0.4mg/kg (10-40mg) at induction, after midazolam, then bolus as needed

Prehabilitation

Peri-op shared decision making

An important question might be along the lines of ‘are there any outcomes for you that would be worse than death?’

5th East Midlands Critical Care Conference – take home notes

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Leadership & Management – Merrill & Reid Social behaviour types/personalities. Know who you are and who you are dealing with.

Click to access Personality%20Categories.pdf

https://www.gotoquiz.com/your_personality_1

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Anaesthesia for PH/protecting RV – Goldilocks. Not overloaded, not undefiled, must be just right.

Pulmonary Hypertension: sPAP>40mmHg, mPAP>25. sPAP = RAP + 4x[TRVmax]^2

Mort 5%

ECG: strain pattern. RAD. ST depression V1- V4

On echo: TR Vmax = underestimate.

RHS: TAPSE<15mm, RV thickness >5mm (in diastole)

Tips: Open, not laparoscopic surgery. A-line + CVC. Avoid ketamine/des/N2O (as they increase PVR). fiO2 0.6, PEEP 5-8. PaCo2 4-4.5. Warm everything. Post-op HDU/ICU. Phone a friend – local/own PH unit. Should they be for full MOS? What is disease trajectory? Beware NYHA Class 3-4.

Signs of problems: High CVP + low BP, low SpO2, reduced end organ perfusion. Consider cautious fluid bolus 150-200ml OR diuretic. Optimise ventilation, Keep in SR (Amiodarone +/- DCCV), avoid b-blocker. Start norad +/- vasopressin. Then adrenaline. Then milrinone. Then iNO, epoprostenol

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Liver failure.

Think: Is it the culprit or a bystander? Is it treatable? What further investigations (imaging, bloods, bx) will help?

Mortality: encephalopathy > ascites + bleed > other

Citrate RRT seems to be safe. However need to consider low Ca2+:Ca2+ ratio. Monitor for accumulation + toxicity

Use albumin for high volume replacement. Evidence only for paracentesis.

Adrenal dysfunction, so consider steroid (hydrocortisone 50mg qds) if increasing vasoconstrictor.

In GI bleeed -> start NG feed early (despite ‘protein load’ )

Prophylaxis antibiotics

Early TIPS

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Obesity

BM ventilation usually is biggest challenge. DL usually is ok – though increased difficult predicted in neck circ > 40 cm (especially > 50cm) + MP3. Apples worse than pears.

Proposed induction strategy:

Pre-O2 in ramped position, fiO2 0.8, PEEP 5-10

Early iGel instead of BMV

Muscle relaxant

Video laryngoscopy

If predicted difficult DL/VL + can’t access neck think AFOI

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Need patient centred (not doctor centred) outcome measures. Ideally standardised.

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On fatigue. Samn Perelli scoring system.

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Vitamin D

In UK all population at risk of Vit D def which increases mortality which can be treated/reversed with treatment. Jury is out on ICU treatment of Vit D, however screening and treatment may be prudent/pragmatic.

VITDAL – ?

Currently in progress VITALISE, VIOLET

Vit D3 better than cholicalciferol.

Should we screen pre-op?

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Frailty.

Consider having electronic frailty index (based on Rockwood method). Works with EMIS and SystemOne.

Assessment methods: Gait speed, Clinical Frailty Score, Edmonton Frailty Score

 

The Art of Being Brilliant

Take home messages:

  • Make a TO BE list rather than a TO DO list
  • how would the best version of oneself go in to work? – energetic, creative, resilient, positive, confident, upbeat, happy
  • Zig Ziggler
  • Vipassana Vendatta
  • Can choose to be positive vs be a mood hoover
  • Do not moan. ‘get over it’ choose to be positive, be grateful
  • If you did know the answer what would it be? If we were the best team, how would we act?
  • ratio of good/praise to bad/negativity:
    • 1:1 high risk
    • 2:1 at risk
    • 3:1 – minimum for good relationship
    • 6:1 – high performing team
    • 8:1 – children
  • 1st FOUR MINUTES = be the best self.
  • Reframing positively e.g. ‘was it good, great or amazing?’
  • Appreciative enquiry – meeting and discussing what went WELL

Andrew Cope

The Art of Being Brilliant – mentoring update

@beingbrillaint

14th Annual Critical Care Symposium

Ventilation

6ml/kg, <30 cm H20, PEEP, SpO2 94-98%, recruit

 

Trials to review:

Recruitment, FEAT, FACTT, ACBIOS

 

Successful ward round

Patient, Doc, nurse, MDT

My name is (first name) to team, Dr xx to patient. call them by surname

Family present at WR. Adv: gain new info, open/honesty. Pre-claimer. Teach & treat.  Will translate.

White board next to each patient with important info, plan details.

Start at same time everyday – good for MDT

Daily plan understood by all, nurse/junior repeats back. To do list. Check

Interactive, educational, professional, fun

 

Crit care practitioner

service need, fill rota gaps. crit care practitioner podcast

robust ciricullum, education, cpd + appraisal pathway/training. Some can prescribe. know your limits. consistency, permanent

P. paradoxus – downwards swing in pleth/BIP in SV patient on inspiration

Digital Meeting

Positive reporting in Datix

Education – twitter journal clubs

‘Rapid weaver’ – Mac based website development

Safety events/handoever every 12 hours

[c.f. neonates WR – learning point of the 24 hours/week]

ipad/screen next to ABG with learning message

Use raspberry Pi

Check out portsmouth crit care