Intensive Care Network Podcasts

Frailty is a state of reduced physical, physiological and cognitive reserve. Tools to measure frailty which were developed in geriatric medicine practice, have over recent years been applied to patients admitted to the Intensive Care Unit (ICU). Studies in the ICU suggest that frailty is associated with reduced reduced likelihood of discharge home and reduced survival at one year. Survivors also report lower quality of life measures on both physical and mental assessments. The most common of frailty assessment tool used in the ICU, is the Clinical Frailty Scale which has also been recently adopted by The Australian and New Zealand Intensive Care Society (ANZICS) as part of routine data collection on all ICU admissions. Last year, for the first time 39 sites submitted data about frailty on over 10,000 ICU admissions. Frail patients were more commonly older women admitted with medical diagnoses. Even after adjusting for age, medical co-morbidities and acute severity of illness, frailty was an independent predic

This presentation will outline current Choosing Wisely projects happening in ICUs around Australia. It will also discuss the Choosing Wisely Australia campaign and its direction.

Lung Recruitment in ARDS - To be or not to be by Dr Swapnil Pawar 

International outcomes of centres performing ECLS (extracorporeal life support) are highly variable due to differences in patient selection, cannulation technique, practitioner experience and hospital volume. We describe the experience of one of the first regional intensive care units in Australia to provide both VV (veno-venous) and rescue VA ECMO (veno-arterial extra-corporeal membrane oxygenation).   Methods  Review of internal registry and description of processes and procedures in an 11 bed regional general ICU without on-site cardiothoracic surgery.  Results  Over a 3.5 year period 21 patients received ECLS (90 ECMO days) with an overall 55% survival. All cannulations were peripheral. 4 patients were retrieved from peripheral site. 8 patients subsequently transferred to quaternary centre. Overall survival for VV ECMO was 64% (n=11), rescue VA ECMO (n=12, 8 from E-CPR) 33% survival.   Conclusion  Provision of ECLS (extracorporeal life support) in large regional centres is possible with outcomes similar t

Since the H1N1 influenza pandemic of 2009 there has been a dramatic increase in the number of patients receiving ECMO and in the number of hospitals that provide it. Data from the Extracorporeal Life Support Organisation (ELSO) suggests that over the last decade the number of adult patients receiving ECMO for respiratory support has increased at least 12-fold and the number of centres submitting data to the ELSO registry has tripled.  The approach to the provision of ECMO in NZ and Australia has been very different, with Australia seeing a huge increase in the number of ECMO centres since 2009 (there are now at least 17 centres in Australia) whilst NZ has continued to have a single national service based in Auckland.  Multiple studies suggest a significant outcome benefit for patients treated at high-volume ECMO centres (defined as those with >30cases per year) compared with “occasional” users and guidelines from the UK, NZ and elsewhere recommend that its use be restricted to expert centres that integra

Optimising support by Dr Susanna Price

I will consider this question in two parts;   Should ECMO be considered for all patients?  Should ECMO services be provided in all ICUs?    From a patient perspective, ECMO is a highly invasive intervention and like every other intervention that we consider, the benefits it provides must outweigh its risks for it to be worthwhile.   Clearly, veno-venous and veno-arterial ECMO supports are very different beasts – the patient profile, physiology, complications and outcomes differ considerably. At the extreme of the VA-ECMO spectrum is ECMO-CPR (e-CPR).  Whilst ECMO centres nationally and internationally have published indications and contraindications (which will be discussed), to make decisions around an individual case it is helpful to understand the burden that ECMO support imposes.   For patients this is the physiological burden of being placed on ECMO. This includes frequently the need for ongoing sedation and lack of mobility, the non-physiological cardiorespiratory effects conferred by E

Use of Ventricular Assist Devices (VAD) and heart transplantation (HT) for end stage cardiac failure have increased significantly in recent decades. These support strategies hold inherently different risks in the face on non-cardiac critical illness, and require multidisciplinary team management.   According to INTERMACS, more than 2500 VADs/year are implanted the USA. Most implanted devices are continuous flow left-VADs (75%) which deliver systemic cardiac output directly related to pump speed and inversely related to pressure gradient across the pump. Improved survivorship has resulted in increasing outpatient management, however 12-month mortality is 12%, and 1/4 of patients within 1-year post-transplant. Systemic illnesses may also be associated with chronic immunosuppression, for example malignancy and unusual presentations of infectious disease; as well as medication toxicity where the post-transplant medication cocktail exacerbates underlying renal insufficiency and multi-organ dysfunction. Therapeutic

Both cardiac transplantation and durable mechanical support with ventricular assist devices (VADs) have a parallel history – poor results to begin with followed by progressively improving results with more targeted immunosuppression, better recipient selection, improved diagnosis and treatment of rejection and opportunistic infections (cardiac transplantation) and a major step forward with replacement of pulsatile pumps by continuous flow devices (VADs).  Heart transplantation continues to be regarded as the gold standard therapy for end stage heart disease and that is why there is a rather artificial VAD indication classification – bridge to decision, bridge to transplantation and destination therapy.  It is the dynamic nature of heart failure and its treatment that may mean a VAD patient may move in and out of these designations.  This would argue for a single designation – indication for a VAD.    The automatic assumption that patients who have a VAD implanted should proceed with listing for cardiac transp

This talk with discuss the indications for, contraindications to, and expected outcomes after heart transplant with a focus on the New Zealand and Australian experience.  I will discuss the transplant assessment process and listing criteria.  Perioperative and long term management of heart transplant patients will be covered.  Post heart transplant outcomes (morbidity and mortality) will be discussed.  I will discuss organ donation with a focus on the donor heart, covering what criteria we use to determine if a heart with be suitable for transplant.  At the end of the talk attendees will have an understanding of which patients are likely to benefit from heart transplantation and the short and long term outcomes after transplant.

Talk will discuss the use of ECMO as advanced cardio-pulmonary resuscitation in the setting of refractory cardiac arrest.   The aim will be to provide useful information for those already experienced in ECPR as well as those with no experience but an interest in establishing an ECPR in their adult centre.   Topics covered will include the rationale for the use of ECPR , the evidence base and current Australasian practice.  Practical issues re patient selection , cannulation , post cannulation management of haemodynamics , monitoring and ongoing management of the ECPR patient will be covered.  Potential future directions for ECPR will conclude the talk. 

Extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (ECPR) is an effective therapy to improve outcomes for children who experience cardiopulmonary arrest. Survival after ECLS varies between 60% and 75%. For ECPR survival is lower, with 40% to 50% of children surviving ECPR. After ECPR good neurological outcomes are seen in 40% to 60% of children. This contrasts with adult patients where neurological outcomes after ECPR are poor. Given these findings the American Heart Association has included ECPR in their 2015 guidelines for children who experience an in hospital cardiac arrest (IHCA).  Several modifiable and non-modifiable factors have been identified as influencing outcomes after ECPR. Location (in-hospital versus out-of-hospital[OHCA]) of cardiac arrest as well as pre ECLS CPR duration impact survival. For children, OHCA is generally viewed as a contraindication. However patients who achieve intermittent output during their OHCA may still qualify for ECPR, particularly if they show

Patients admitted to the ICU after cardiac arrest have, by definition, achieved ROSC. In such patients the major issues remain those of ongoing support hemodynamic and cardiorespiratory support, cerebral protection, aetiological diagnosis, and rapid intervention to deal with the underlying trigger (coronary angiography and stenting of coronary artery disease or CT pulmonary angiography and anticoagulation/thrombolysis for PE). Once the aetiological diagnosis has been made and its cases addresses and cardiovascular stability has been achieved, the priority of care is directed toward cerebral protection. Previous randomized controlled trials had suggested that hypothermia would deliver superior neurological outcomes compared to usual care. However, methodological concerns led to a further large trial of strict normothermia (TTM-1) which found strict normothermia to be equivalent to hypothermia in terms of neurological outcomes. Such findings have led to the design and randomization of patients with out of hospi

The good news in resuscitation is that there have not been any new advances that mandate a change in practice since the 2016 ANZCOR Guidelines. The bad news is that despite our best intent, the ever-increasing research appears unable to demonstrate improved outcomes with any particular approach. Two of the most exciting areas (eCPR and post-resuscitation care) are being covered in detail at separate talks at this meeting. This presentation will focus on updating the audience on the more continuous approach to evidence evaluation, and the key recent publications that have made us at least re-evaluate our practices in BLS (including ventilation), ALS (including anti-arrhythmics) and peri-resuscitation care. 

The Fellowship abroad: Dr Peta Alexander Research Fellowship: Dr Elissa Milford Simulation Fellowship: Dr Sile Smith Trauma Fellowship: Dr Fraser Magee Echo Fellowship: Dr Sebastian Knudsen

Renal Replacement Therapy: When to STARRT? by Professor Andrew Udy

There has been a potpourri of papers released in the last 12 months of interest to Intensivists. Some have solved the great mysteries of the universe, some have sparked the interest for more high-quality research and others have left us scratching our heads. This talk will give a snapshot of the Top 10 Critical Care papers of the last year. 

Basic bronchoscopy skills are considered a core component ability for all Intensive Care trainees. A few simple tricks to remember anatomy can make a relative bronch novice look like a seasoned pro. Remember 4 rules when looking down a bronchoscope:  Walls to the back  Every bronchus looks the same as every bronchus once you have already jumped in, so always identify the posterior wall to orientate yourself  Carina is your friend – visit her often.  Everyone gets lost. When this happens, don’t go on, go back to the carina  The right middle lobe and lingula are anterior anatomical structures  When you look down a scope, the right middle lobe is not in the middle, medial or any other stupid word beginning with ‘m’……….it is anterior, seriously!  The apical segment of the lower lobes is a posterior anatomical structure.  The fact that you even know this thing exists will so impress your colleagues and boss that no one will dare ask you any other bronchoscopy anatomy questions. 

This short talk will focus on the who, why, how, what, and when of diagnosis and management of pulmonary hypertension and the right ventricle:  Who gets pulmonary hypertension?  Why is pulmonary hypertension important?  How do I diagnose pulmonary hypertension?  What are the most important practical management strategies?  When should I use advanced monitors and expensive pharmacotherapies?  Both acute and chronic pulmonary hypertension will be discussed, and the emphasis will be on practical management of patients in the intensive care environment. 

Acute liver failure for the intensivist by Dr David Anderson