Tag Archives: Management

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.

http://www.ucd.ie/t4cms/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

 

NHS Consultant productivity

A very interesting article and comments, arguing that although Consultant numbers have increased,  Consultant productivity has decreased due many systemic factors including workforce planning (including lack in increase in nurses), social and community care capacity limiting patient flow, and capital e.g. lack of ICU beds, IT infrastructure.

Many questions are raised though, such as how can ‘productivity’ be a accurately and meaningfully measured in a useful and comparable way in such a complex system. Also, how does one account and value ofter features such as quality and safety? It’s complex!

Link: http://www.bmj.com/content/356/bmj.j1520

 

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

GAT conference take home messages

Tips:
Give IM atropine with IM sux
In obese O2 consumption is significantly greater during SV rather than IPPV
Epidural blood patch recommend 20ml
Dural puncture: inject 20ml normal saline down intrathecal catheter
NSAIDs may affect  platelets and clot strength of EBP
In difficult airway consider nasendoscopy.
AFOI topicalise. Reduce secretions by suction catheter or Yanker (also tests topicalisation)
Legal position: Prudent doctor  -> prudent patient
Coding – appropriately – gets the organisation appropriate money
Quality measures – e.g. length of stay
How to add value ? Outcome or quality / cost
In a report, if used a guideline say so
Detail discussions with patients, including apologies
References to read/watch/review:
‘Perfect storm NHS funding’
Cardiac arrest in neurosurgery patients

Cliff Reid YouTube videos
DOLS
NICE guidelines on trauma
BATLS, ATACC course
Kirkpatrick model (for simulation)