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Critically ill patient withAlcoholic liver disease –Is it worth it?
There is a general perception that providing multi-organ support, or even admission to
critical care, is futile for patients with alcoholic liver disease (ALD). The incidence of ALD is
increasing in many countries, especially among younger patient populations. As a result
patients are frequently referred for consideration of critical care when developing prevalent
complications such as variceal bleeding, encephalopathy, and sepsis. Multi-organ failure
frequently complicates these complications, especially cardiovascular, respiratory, and renal
failure. This lecture will review the current epidemiology of ALD outcomes following critical
care admissions. Specifically, those factors that are associated with poor short term outcome
will be described, and recent population-level data from Scotland presented evaluating short
and long term survival.
Reading
P. A. Berry, S. J. Thomson, T. M. Rahman, A. Ala Review article: towards a considered and
ethical approach toorgan support in critically-ill patients with cirrhosis. Aliment
PharmacolTher2013; 37: 174–182
Using quality improvement toimprove sedation management.
Sedation is among the most prevalent ICU treatments. There is strong evidence that deep
sedation is associated with longer ICU and hospital stays, higher rates of infection, and
potentially higher mortality. More prolonged periods of deep sedation and “unformed”
memory are also associated with higher rates of late psychological morbidity, especially
post-traumatic stress reactions. Intervention studies suggest that strategies to avoid
excessive sedation are clinically and cost-effective. However, the optimum methods for
improving sedation quality are uncertain. Some, but not all, evidence supports the use of
daily sedation breaks; these have been a focus of many quality improvement programmes,
sometimes as part of the ventilator bundle. However, sedation management involves
avoidance and improved management of agitation and pain in addition to deep sedation. A
potential consequence of interventions focussing only on deep sedation avoidance is an
increase in agitation and pain, which are highlighted as unpleasant by patients.
In other areas of ICU care, especially the management of hospital acquired infection, the
development of robust quality metrics together with methods for tracking and plotting these
over time has enables the effects of novel interventions to be monitored and evaluated using
Plan-Do-Study-Act and similar cycles of quality improvement (QI). This talk will describe our
work, part of a QI programme for sedation practice in Scottish ICUs, to develop novel ways
of describing pain, agitation, and deep sedation and plotting these over time using “process
control charts”. Data from 12 months of sedation quality monitoring for 8 Scottish ICUs will
be shown to demonstrate the potential for this approach to drive QI programmes that
improve patient comfort and sedation quality.
Reading
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain,
agitation, and delirium in adult patients in the intensive care unit. Critical care medicine
2013;41(1):263-306.
Tutorials
Optimising Blood use in ICU
Up to 80% of ICU patients develop anaemia, and 25-50% will experience a haemoglobin
(Hb) <90 g/L during their ICU stay. 40-50% of ICU patients receive a red blood cell (RBC)
transfusion during their ICU stay, and critically ill patients utilise 8-10% of all RBCs.
Emerging evidence has suggested that RBCs may have adverse effects, including
immunomodulation (increasing hospital infections), pro-inflammatory effects, pro-thrombotic
effects, as well as the well –documented transfusion-related complications such as TACO,
TRALI, and very rarely infection transmission. The risk to benefit balance of RBCs for the
critically ill is highly relevant to our patients.
Much of our belief that restrictive use of transfusions is safer for critically ill patients comes
from the TRICC trial, where using a trigger of 70 g/L and targeting Hb 70-90 g/L during ICU
admission had similar outcomes to a more liberal approach. The outstanding questions
relate to which sub-groups of patients, if any, should have more liberal RBC transfusion
triggers. Several important studies have been published recently that inform our thinking: the
TRISS trial [1], the TiTRE II trial [2] ,the “Villanueva trial” [3], the ABLE trial [3], and a recent
systematic review of RCTs of liberal versus restrictive transfusion practice [5].
This tutorial will discuss the recent evidence, and where the certainties and uncertainties are
for the use of RBCs in the ICU.
Reading
1.
2.
3.
4.
5.
Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for
transfusion in septic shock. NEJM 2014;371(15):1381-91.
Murphy GJ, Pike K, Rogers CA, et alfor the TITRe2 Investigators. Liberal or Restrictive
Trans fusion after Cardiac Surgery. N Engl J Med 2015; 372:997-1008
Villanueva C, Colomo A, Bosch A, et al. Trans fusion strategies for acute upper
gastroint estinal bleeding. NEJM 2013;368(1):11-21.
Jacques Lacroix, M.D., Paul C. Hébert, M.D., Dean A. Fergusson, Ph.D., et al. Age of
Trans fused Blood in Critically Ill Adults. DOI: 10.1056/NE JMoa1500704
Holst LB, Petersen MW, Haase N, et al. Restrictive vers us liberal trans fusion strat egy forred
blood cell transfusion: systematic review of randomised trials wit h meta-analysis andtrial
sequential analysis. BMJ 2015;350:h1354.