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ESICS

Two Years On

Jason Leith

  • This was his talk about his experience/scottish government's response

Global Perspective

  • Eamon

  • Reema Patel

  • NHS Scotland - Global Citizenship Programme

Poster Prizes

  • Ellen Pauley - Med Student:

  • Turns out that covid ICU patients had less follow up fatigue than the rest of the ICU patients

  • Andrew McGowan

From Cradle to Grave

Arlene Wise - MBRRACE

  • If you are doing ALS on a pregnant patient, do uterine displacement rather than left lateral tilt:
    • It's harder to do a tilt on a trolley

  • The majority of patients (non covid) are admitted to ICU post natal rather than pregnant

  • What are the staff in Obstetric HDU's

  • All midwives, not critical care trained
  • What's provided?:
    • A Lines
    • Bakri Balloons
    • IV Hypertensives
  • Rarely central lines, rarely vasoactive to bring BP up
  • So really Obstetric HDU will be Level One Enhanced Care

Covid Maternity

  • So this was predominant antenatal

  • What should we look at? The 4P Study

  • Circulating volume in pregnancy is 100ml/kg

  • What vasopressors to use? - Phenylephrine or Noradrenaline

  • What should you do re: delivery?:

    • Usually 27 weeks and under leave
    • Usually 32 weeks and over deliver
    • Who knows in between - D/W MDT
    • Aim of delivery here is to improve ventilator etc
    • PLANPLANPLAN
    • Deliver in theatre is better
    • Drugs - what drugs? doesn't matter:
      • Generally don't recommend ketamine as neurotoxic foetal
      • But if they're sick use what you are comfortable with

Lindsay Ford - Paeds

  • Don't cut a paediatric tube
  • Aspirating ng tube will help ventilation a lot pre intubation
  • RR25-30 even in young ones
  • oxylog-3000 are rubbish for under 10 kgs
  • catheter mount angle piecee and filter are the dead space they care about

Natalie Pattison - Palliative Care

@drnatpat

  • Scale: 1/7 die in critical care = 27000 deaths:
    • 1/2.5 died in ICU in covid peak
    • 1/3 of deaths is in first 24hrs
  • Time from withdrawal decision to death is around 36hrs

  • Mean age of death in critical care was 66 in scotland in 2021 study - Mayes 2021 BMJ

  • Extubation less favoured in UK

  • Compared to US, UK patients are sicker, and more often ventilated

  • Studies on decision making:

    • Wide range of interventions tried
    • With v weak evidence base
    • especially where the studies look at length of stay
    • What outcomes should we use?:
      • Healthcare utilisation
      • Patient centred outcomes/bereavement outcomes
      • What about a POOR OUTCOME Set

  • Hua - Showed time to death is directly related to length of stay and strain

  • Jo Cosgrove? - Other people to comment

  • Chris Bassford?

  • realtalktraining.co.uk/urgent-conversations-withdrawing-witholding

End of Life Care

  • Symptoms
  • Withdrawal
  • Outcomes

  • Organisation

  • Timing of withdrawal - median time from withdrawal to death was 2.4 hours

  • ICU specialists are OK at predicting death (50% of time)

Transfer

  • About 20% of patients dying in ICU would have been appropriate to go home to die - 2017 study

Symptoms

  • Puntillo:
    • Thirst is most intense symptom in ICU in patients at risk of dying
    • Fatigue also up there
  • Thirst:
    • Water sprays
    • Lip moistureisors
    • Puntillo K 2014 ICM 40
  • How should we manage hunger
  • Dyspnoea:
    • What scales should we use?:
      • BPS Scale - Intubated an non intubated
      • Facial movement, upper limb movement, ventilator movement
      • Air hunger, work of breathing, chest tightness, tachypnoeea
  • Pain:
    • How should we document management of it?
    • When pain is 40% incidence
    • Fentanyl is particularly good in critically ill patients being turned

Extubation

  • Withdrawal
  • Should that be one step or in small intervals, we don't know - in terms of length to death, or symptoms

  • Should we do vasoactives first or ventilate

  • ARREVE Extubation Study:

    • More common to see airway obstruction and pain scales
    • No difference in grief and PTSD
    • In comparison to terminal weaning
    • So maybe we shouldn't be extubating them???
  • Outcomes:
    • There is no consensus currently
    • There are Person-Centred Outcome Measures in End-Of-Life in Critical Care being developed

Bereavement + Death Trajectories

  • Expected vs Unexpected

  • Rapid vs Chronic

  • Should look at the CAESAR tool for bereavement assessment in ICU (as opposed to FS-ICU 24)

  • Condolence letters can worsen family depression at 3 months (at one french study)

COSMIC-ICU

  • A bundle of care can reduce the incidence of prolonged grief at the end of life

CANDID+ Study

  • Looks at cognitive dissonance and moral injury and PTSD

Critical Care Research

  • COVID-19 meant research patients enrolled doubled for 2020
  • There are 11000 critically ill patients admitted to critical care each year:
    • 60% are ventilated