Critical care 2013, issue 4

ISSUE 04

Mapping the future of critical care T

he only certainties seemed to be uncertainties as the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine drew to a close.

For both Satish Bhagwanjee, director of the Critical Care Training Program in the Department of Anesthesiology at the University of Washington Medical Center in Seattle and Jean-Louis Vincent, professor of intensive care at the Erasme University in Belgium, the diverse range of people either affected by or practicing critical care medicine, the wide range of cultural influences and even contradictory scientific evidence meant a balanced approach and a great deal of imagination had to be applied.

In describing the process behind the Durban Declaration which was created as both a legacy from the international

Professor Jean-Louis Vincent

By SHIRLEY LE GEURN congress and a road map going forward, Bhagwanjee said that there was an incredible ignorance about critical care generally and that many people directly affected by it were “blind and lost”.

Complex interventions and care decisions needed to be made within ICUs to ensure that the right medical outcomes were achieved and this was made even more complex when a team dynamic came into play, he said.

Across the board, he stressed, ethical imperatives, cultural differences and the unequal distribution of resources and infrastructure always needed to be taken into consideration. He said it was not “about dollars available” but about the immense diversity which necessitated a better and clearer description of various issues as well as imagination enough to know that things would never be straightforward,” he said.

Vincent, in asking how far critical care had come since the 10th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Florence in 2009 also stressed that “things were not necessarily black and white.”

He said that in the scientific research realm, there had been a lot of contradictory studies with many negative outcomes. However, all role players needed to consider a balance between the positive and negative effects of different interventions and individualise treatment according to the needs of the patient.

He said that one of the major questions had to be where were the studies that showed beneficial effects of therapies such as fluid and electrolyte therapy, the use of steroids, anti-oxidants, sedation, strategies to address hypoxaemia and issues surrounding ventilation amongst others. He said studies had delivered

both yes and no answers – as well as “we will see” ones that returned to square one with no definite conclusion and a need for future research.

Asking why there were so many negative trials, he explained that it was not a matter of power, the subject or even the size of the study. A major influence was the heterogeneity of the populations in which researchers are operating. “Often we have to consider and interrogate the fact that some of what are believed to be major benefits could do a lot of harm,” he pointed out.

When it came to treatment, especially when dealing with the likes of sepsis for example, intensivists needed better biomarkers, he said.

Vincent said that, of late, big random control studies appeared to be done with a view to eliminating treatment studies rather than to add positive measures.

He said that current literature always delivered a “no” verdict which was quite depressing. Looking to the future, he added: “We like to criticise everything but we need to look at what works. We need to go over things again and again.”

Nevertheless, Vincent believes that researchers and intensivists can be proud of what has been achieved through collaborative studies. He also highlighted the fact that studies such as these, backed by modern technology, would deliver large databases, would allow researchers to ultimately extract a great deal of valuable data.

“However, my point is that the future is not only about big random control studies,” he stressed, adding that intensivists could be smart and achieve a deal through extrapolating the findings from smaller studies that could improve care for the critically ill. “You can base your decisions on small trials.

It is not only big trials that will make a difference,” he said.

Pan-resistant antibiotic era looms

T

he global surge in the incidence of tuberculosis (TB), growing mortality rates and the emergence of increasingly drug resistant strains of TB has been a serious wake up call. As a result, there has been a sudden upsurge in research into new drugs.

However, the tragedy is that it could take another five to 15 years for these to become widely available.

Umesh Lalloo, from the Department of Pulmonology at the University of KwaZuluNatal’s Nelson Mandela School of Medicine, told delegates at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Durban that, although a number of new TB drugs were already under investigation, none had yet been registered in South Africa.

Nevertheless, he hoped that they would be soon.

Highly critical of complacency on the part of the World Health Organisation (WHO) which believed that TB would ultimately be eradicated and failed to recognise the need for new treatment regimes, Lalloo said that not much had been achieved since the days

By SHIRLEY LE GEURN of Nobel prize winner Robert Koch who earned the ire of the scientific community for failing to contain TB via the development of a vaccine. “150 years later, we have still failed to eradicate TB with everything we have, so we need new drugs,” he said.

He pointed out that multi drug resistant (MDR) TB first surfaced during the eighties but it took until 1993 for the WHO to declare TB a global emergency. The time lost meant that the two front line TB drugs used today - isoniazid and rifampin – still dated back to the fifties and sixties.

“In Africa, where have a high burden of HIV, the incidence is predicted to be 600 per 100 000 (inhabitants) by 2015,” he said, pointing to a yellow line on a graph that showed a far higher rate of infection in South Africa which, he said, had successfully doubled the incidence of TB in 15 years. With the world incidence averaging just over 100, South Africa was doing badly, he said.

He said that MDR TB, about which many had been skeptical until recently, called the

world to order when it came to finding new TB drugs. “Unfortunately it’s a scourge that we have invited due to our poor control of TB. If you look at global estimates of TB, you can see clearly that it is shocking and not surprising that, with increasingly drug resist TB, the mortality is higher.”

Lalloo said that extensively drug resist TB – which was even more serious – had only been discovered during research just 300 kilometres outside Durban in Northern KwaZulu Natal. “We wanted to combine HIV and TB treatment and found 16 percent mortality. We thought the HIV drugs were killing the patients.” It was only when they delved into this further that they exposed the true extent of the problems associated with drug resistance.

Lalloo warned against further complacency highlighting that four cases of totally drug resistant TB had recently been reported from four different places in India. “It’s a looming threat for us in our environment,” he said, adding that in the ward in which he worked, up to 100 percent of MDR TB patients died. Although there were suspicions that these patients could be totally drug resistant, he said this was not known conclusively.

“Right now, we have a limited no of first line drugs which are the most effective. As you move to second and third line drugs, they become less and less effective, more toxic and much more expensive,” he said.

Lalloo said that the wish list for a new anti TB drug was a long one. It needed to be absorbed well orally, preferably require once daily dosing, have a wide therapeutic window and be effective against both dormant and actively replicating bacteria at the same time, have a low propensity to develop resistance and be synergistic with other TB drugs as patients presenting with TB had complex needs and needed multiple drugs. it also needed to be affordable. First prize would be a drug that could shorten the duration of TB still further.

Examples of new drugs on the horizon include bedaquiline which is already available in America and seems to be safe with few side effects. It also promises to be effective in the treatment of MDR TB and linezolid which is already well known to those in the critical care environment but is extremely expensive.

However, Lalloo warned, abuse of these new drugs would take everything back to square one – a strong possibility given the track record of other TB drugs in the local healthcare environment. For this reason, those waiting for new drugs needed to use those that were available responsibly and effectively and to look into non-drug based treatments such as the use of vitamin D and vaccines.

“Within the next five years, we will see a whole new category of agents avail to treat TB. In the meantime, we can’t be complacent. We need to use our current available drugs properly and eradicate drug sensitive TB,” he said.

Brace for growing numbers of obese patients

H

ospitals and critical care clinicians need to adapt to deal with the global epidemic of obesity with 400 million people already classified as obese and a further one billion classified as overweight.

Dr Mary Pinder of the St Charles Gairdner Hospital in Western Australia focused on the risks faced by the obese and the challenges of diagnosing sepsis.

Pinder said obesity was an increasing problem in developed and developing countries.

“Obesity combined with sepsis is a really important topic for those of us in critical care because it is almost a perfect storm - the increase in the incidence of obese patients and sepsis being one of the most prominent issues we have to look out for in the emergency care unit,” Pinder said.

“If you get the diagnosis wrong and over diagnose sepsis when there isn’t sepsis we put that particular patient at risk and we put other patients at risk by increasing the risk presented by antimicrobial resistance.”

“We also put patients at risk by missing a true diagnosis and if we under diagnose sepsis obviously that has a significant impact,” Pinder said.

Pinder said there was debate regarding whether calculating BMI or measuring waist circumference was the preferred measure of assessing obesity.

Pinder said in terms of weight classification normal weight was a BMI (Body Mass Index) of between 18,5 and 25, overweight was a BMI above 25 and obesity was classified as a BMI over 30.

Using waist circumference assessment, a measurement over 94 cm classified men as overweight, while a measurement of

By LYSE COMINS 80 applied to women. Men with a waist circumference above 102 and women with a waist circumference over 88 were classified as obese.

Pinder said obese patients were at higher risk of skin, soft tissue and surgical site infections as well as acute pancreatitis. She said research had also shown obesity was a “significant” risk factor for the 2009 H1N1 influenza outbreak and was associated with poor outcome. Additional risks included maternal sepsis, while obesity was an independent risk factor for future sepsis.

“On the upside, there is the obesity paradox. Although these patients are more at risk of certain infections there is evidence that their outcomes are better,” Pinder said.

“Studies are conflicting but there is evidence that obese patients do better than non-obese patients in some conditions, including heart failure and sepsis.”

Pinder said there was a need for further research because there might be other factors involved such as the overdiagnosis of infection and different mg/ kg doses of antibiotics.

However, Pinder said diagnosing sepsis in obese patients could be difficult.

She it was hard to complete a thorough examination as it was not easy to turn patients.

“Accessing potential samples to do a sepsis screen can be difficult. Just obtaining a vein to get blood cultures is tricky. The risk of contamination with skin and any fungal skin infections is high and that makes interpretation of the situation difficult,” Pinder said.

Dr Mary Pinder

“As this is an increasing problem we need to get better at our examination technique, starting with medical students. They should be focused on practicing examination techniques on patients on all size ranges to get that level of expertise.”

Pinder added that imaging such as x-rays and scans presented a big problem with the main issues revolving around difficulties with patient transport, scanner weight restrictions, image acquisition and interpretation.

“In our hospital when we tried to transport obese patients to the scanner some of the passageways and doorways weren’t wide enough to get the bed through. Some lifts weren’t big enough to accommodate the beds and once you get down to the scanner some of the little corridors with all the equipment they have stacked there are not very friendly. They don’t have any additional hoists or equipment,” Pinder said.

“In areas where there is a significant population of obesity these things need to be planned for and in any expansion or modification or building of new hospitals these things need to be put in place,” Pinder said.

Pinder said a major problem had been scanner tables with 150kg to 200kg weight limits as well as technical difficulties with poor quality images, which made it difficult to make a diagnostic decision.

“Manufacturers have modified the new designs so that current models have a much higher weight threshold, which is realistic with the growing problem of obesity,” Pander said.

She added that solutions could be to take images in sections and to use scanning techniques and modification of the scanners to improve quality.

“Some patients end up needing exploratory surgery to make a diagnosis,” Pinder said.

overweight patients pose risk to staff T

here are many challenges facing critical care nursing staff when managing obese patients in ICU, with risk factors for both the patient and the care-giver.

Kathleen Vollman, honorary ambassador of the World Federation of Critical Care Nursing, and United States based private nursing professional explored this subject and offered some solutions at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Durban.

“These patients are two times more likely to suffer from a respiratory event in the post anaesthesia care unit (PACU). Prior to surgery they should be evaluated for sleep apnea so that can be addressed in post operative care,” Vollman said.

She added that according to research

By LYSE COMINS published in the Journal of Occupation and Environment Medicine, 50 percent of nurses required to do patient repositioning suffered back pain. This included obese and non-obese patients.

She said the study showed that 40 % of critical care unit staff performed repositioning tasks more than six times per shift.

According to the leading world experts on safe patient handling the number one cause of muscular skeletal injury was repositioning patients in bed.

When it comes to the patients, Vollman said oral hygiene as well as hydration of the mucosa was important is it could reduce the risk of health care acquired pneumonia and promote comfort. She added that patients should be positioned in bed at 45 degrees reverse trendelenburg (a position with the head higher than the rest of the body).

“Assess heart sounds in a left side lying position. End tidal Co2 may not be reliable so use mental status change,” Vollman said.

She said for cardiac rhythm monitoring landmarks should be identified with indelible marker to prepare the skin for electrodes.

“A regular blood pressure cuff on the forearm is more accurate than a larger cuff around the upper arm. Make sure the forearm is at heart level,” Vollman said.

Vollman said that when it came to imaging, a 15 year retrospective study looking at obese patients found that 750 000 imaging procedures were limited due to body size.

Patients with a Body Mass Index (BMI) of more than 40 needed also more time for procedures.

Vollman said patients may present with pre-existing skin problems such as diabetic foot ulcers, venous insufficiency ulcers, lymphedema (swelling in the legs), intertrigo (infection of the skin folds) and psoriasis.

Alexander Van Der Sluijis from Amsterdam said he found the quality of the speakers to be very high and he also wanted to visit South Africa.

“Obese patients are more susceptible to pressure, moisture and shear injuries (injury caused by dragging the body over a surface).

The catheters placed in various orifices can get buried between the folds and create pressure sores,” Vollman said.

Vollman said there was a need for appropriate sized equipment such as 454kg beds and sufficient staffing levels.

“If you don’t have the appropriate equipment, you may not even have the diameter within a bed to turn (the patient),” Vollman said.

She said additional challenges were the patient’s clinical condition, and the risk of tissue injury in the skin folds or posterior surfaces, which were difficult to assess.

“I would advise that you put in an overhead trapeze and a hydraulic lift to help with movement. You also have to pay attention to your stretchers, chairs and commodes. All of those have to be big enough otherwise there is pressure or they just simply won’t fit,” Vollman said.

Additional supplies required by units included large gowns, toilets mounted to the floor rather than the wall, larger door frames, larger needles for line placement, longer tracheostomy tubes and equipment to accommodate up to 454 kg.

“During assessment and in each turn it is critical to focus on the folds for skin issues and also the skin near the tubes. Target the abdomen, breast, back folds, thighs, posterior neck and perineal area,” Vollman said.

“Avoid powder, especially baby powder because there is a chemical in it that interacts with the moisture and can contribute to the development of fungal infections.”

Vollman suggested the use of a dressing called Interdry between the folds, to prevent injury; slide and glide turning sheets and foam wedges rather than pillows.

Leanne Aitken from Australia was a speaker at the conference and enjoyed the great opportunity to interact with colleagues around the world and to learn how to improve health care.

Delegates at the 11th Annual Congress of the World Federation of Societies of Inensive and Critical Care Medicine took advantage of a long lunch-hour to browse the more than 72 stands in the exhibition space, and engage exhibitors in discussions about new products and equipment.

Observers were allowed to test equipment themselves and were given comprehensive information about new therapies and treatments.

Aspen Pharmaceuticals set up a ‘roadblock’ to make conferencegoers stop and think about ‘a revolution in generic and branded medicines’. Aspen supplies pharmaceuticals to more than 150 countries around the world and is the leading generics manufacturer in the Southern Hemisphere.

Big five injuries similar to those recieved in war

T

he risk of being trampled, gored or eaten alive by one Africa’s Big Five is directly proportional to the intellectual capacity of the tourist. However, tourists with medical funding who were injured in the bush benefited from superb emergency evacuation services.

This was the word from Professor Jacques Goosen head of the Charlotte Maxeke Johannesburg Hospital Trauma Unit at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Durban.

“The tourism industry in Africa is one of the major growth areas in the South African economy, and has brought a whole host of new challenges,” Goosen said.

Goosen said animals such as wildebeest and hippos, which tourists view as “cuddly little animals” had a “pretty different view” of their audience.

“It is their territory and they will defend it to the death. We are invading it so we are something of a nuisance as a species,” Goosen said.

“For the average villager in Africa, big wild animals are not lovely. They destroy your crops. They trample your children. They eat your cattle.”

However, Goosen said the risk of being injured by one of the big five was “very low” although there was little official data about incidents apart from newspaper reports. However, he said risk was “directly related to the intellectual capacity of the tourist”.

“The more drunk or stupid they are the higher the risk,” Goosen said.

“The most dangerous animal is the human that pokes its nose into everything in every place and invades the space,” Goosen said.

He said big five injuries were similar to war injuries with “enormous” tissue destruction often “coupled with mud, contaminated water and grass” in the wound.

“The only difference between these patients injured in the bush and war surgery is that there is not the dirt, the smell of fear and the smell of diesel.”

Goosen told the story of how surgeons had to repair the chest of a New Zealander who was gored by a wildebeest.

“We had to fix the chest wall because it was completely stoved in by about three to four centimeters,” Goosen said.

Goosen said lions were “probably the least dangerous”, while crocodiles were the most dangerous.

“I am reminded of an Australian who put his hands in the pristine clear water to experience the cleanliness and the beauty of Botswana and he spent two months having his arm debrided,” Goosen said.

Goosen said pre-hospital care was non-existent beyond the Limpopo River apart from in small isolated urban areas.

“The mortality rate at the average small rural African hospital is the same as in the US simply because no major injury arrives at the

By LYSE COMINS hospital,” Goosen said.

Goosen said tourists who were funded benefited from “superb” medical emergency evacuation services. However, he added that the most experienced emergency physicians and emergency medical personnel had left South Africa for Bhagdad and Somalia where the going rate for their skills was $50 000 per month.

Goosen offered the following advice for the treatment of patients with Big Five injuries.

• Patients arrive with a microbial profile of doomsday with colonized bacteria. In a recent case a burn centre had to be closed for six weeks to get rid of a bacterial epidemic after five patients infected with bacteria that had colonized were flown in with burns from a distant country. It is important to realise that the quality of antibiotics and anti-biotic prescriptions are not the same everywhere in world.

• Patients are under-resuscitated and need a lot of work until their multiple organ failure has been controlled. Guidelines do not exist everywhere, especially not in small under resourced environments. For example they do not have knowledge or guidelines on surviving sepsis.

• Vacuum the wounds and keep reassessing them because they are never clean enough.

• Perform the ‘surgery of war’ that involves repeated and aggressive debridement.

Professor Jacques Goosen

WHo gets the bed ? The ethics of PICU W

ith a shortage of ICU beds and high cost of ICU treatment in hospitals, an everyday debate for intensive care practitioners is the question of which children get access to space in ICU and which should be turned away.

At the 11th Annual Congress of the World Federation of Societies of Intensive and Critical Care Medicine, this issue was conducted along the lines of an academic debate, with two paediatricians from Chris Hani Baragwanath presenting real-life case studies, debating the respective merits in each case, and asking the audience to vote for their ‘winner’.

Paediatricians David Kloeck and Harshad Ranchod presented a light-hearted argument, with much banter, but at the

David Kloeck and Harshad Ranchod

By NIKI MOORE core was a very serious issue: what factors should be taken into account when deciding on matters, literally, of life and death.

As the debates and arguments progressed, and the audiences presented their own perspectives, it became clear that there is no right or wrong answer.

Very often the clinician’s imperative to preserve life caused them to delay making these unpleasant decisions.

One case study - a two-year-old boy - was HIV positive with non-Hodgkins lymphoma, had suspected nosocomial pneumonia and suspected fungal sepsis.

He needed ICU because he was going into septic shock. He had no mother, his

extended family had limited finances and they stayed far away in another province.

The second case study was a threemonth old baby with prolonged jaundice, suspected biliary atresia and gastroenteritis who had gone into cardiac arrest and needed to be resuscitated. His very young mother had extremely traditional parents who had forbidden ‘Western’ treatments, and as a result the child had never been immunised.

The debate between the two paediatricians and the audience established that HIV is no longer a factor in determining ICU admission, nor is infection or malnutrition. However, issues that were important were the long-term ramifications of treatment: was there irreparable tissue damage to organs that would necessitate readmissions; what was the social circumstance of the child (in other words, would the hospital save a life which would then face an uncertain quality of existence?); and had the child passed the point of recovery?

Rightly or wrongly, legal ramifications had to be taken into account to prevent relatives from bringing lawsuits against the hospital in the event of a wrong decision, and in certain cases the duty to preserve life was trumped by the duty to prevent suffering.

Another element to be balanced was the rights of the individual against the rights of the community, in a case where treatment might need to be hurried in order to make place for a more important emergency.

However, the consensus was that compassion was important, but that these life-and-death decisions were not pleasant to make and clinicians should not be called upon to make them: they should supply empirical evidence to hospital administrators and allow them to make the call.

This newsletter was produced by the team at HIPPO. www.hippocommunications.com