Dr Mary Pinder & Dr Bronwyn Avard open the CICM 2021 Virtual ASM. Dr Avard will host the day, leading us through our inspiring and educational program.
In her own words, we invite Sherene, an aged-care worker, wife, and mother of two, to share her experience of severe COVID-19 pneumonia. Spending over a month in hospital, including requiring VV-ECMO for refractory hypoxia, Sherene outlines her healthcare journey, her key recollections from ICU, the toll COVID-19 has taken on her overall health and family, and what we can learn from her experience."
The organising committee would like to thank Sherene Magana Cruz for sharing her experience. Presented by Professor Andrew Udy
Victoria reported its first case of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on 25th January 2020. What followed was a roller coaster ride for Victorians involving hard lockdowns, curfews and border closures.
Over the course of the year, 20,000 people were infected, 271 patients needed ICU and 820 lives were lost. 2599 health care workers (HCW) in Victoria were infected with SARS-CoV-2 in the healthcare setting the majority of whom worked in aged care, as nurses or aged-care workers.
Both the virus and the restrictions affected the most vulnerable. The economic and social inequalities were laid bare. Melbourne’s northern and western suburbs, home to a majority low income, casualized workforce, bore the brunt. One health service in the western suburbs managed 21% of Victorians requiring ICU. The Victorian Cluster Response, initiated by ICU Directors and supported by ANZICS worked closely with Adult Retrieval Victoria (ARV) and transferred patients within the state to ensure best care. Consequently, no ICU in the state operated above capacity.
Everyone stepped up. The general public, who stayed home and the frontline workers, who showed up to work. A drive to improve the workplaces and protect HCWs led to innovations. The ‘Patient Isolation Hood’, invented for use in an open ICU was TGA approved and shown to reduce aerosol counts by 98%.
In the ICU, nursing and medical staff worked 12 hour shifts and skillfully managed the critically unwell, providing reassurance to families over a computer screen. They juggled patient care with information overload from constantly changing guidelines and the fear of lack of PPE in the early days. Anxiety, fear, dread, exhaustion- just some of the emotions many described.
All Victorians have worked hard. Currently, there are no cases of community transmission. Perhaps, it is now time to bravely reflect on 2020 to address the social inequalities in our community and the systems that struggled to protect our HCWs. The work needs to continue to keep us together
Western Australia has been extremely fortunate in the COVID pandemic with almost no community transmission due to our relative isolation and hard border. However, we did have a cohort of sick cruise ship patients relatively early in Australia’s experience including the first COVID death. Preparation in WA brought unique issues trying to cover such a large area with multiple small communities. At the end of the day, like elsewhere, this involved a lot of logistics, luck and good will from the critical care and wider medical community
The Queensland Intensive Care Network Covid-19 Pandemic response centred around minimising avoidable loss of life in Intensive Care Units due to the Virus.
Paramount was protecting the Intensive Care Workforce through provision of adequate and appropriate knowledge of the ever-evolving disease, equipment for care, potential rationing of care, and improving centralised organisation, communication and support to all ICUs, to as such “make the whole greater than the sum of its parts’.
The relationship between Clinicians and Politicians was rapidly cemented to facilitate flexibility and adaptability to the emerging threats
Perhaps contrary to popular belief, COVID-19 did not spare Singapore. Not long after a relatively good start at keeping the disease at bay, the number of cases ballooned across the island nation, in large part due to outbreaks in dormitories for migrant workers. This notwithstanding, Singapore’s case fatality rate and number of deaths per 100,000 population remained by far some of the lowest in the world. This talk will describe Singapore’s public health response, with a focus on its intensive care community’s approach, towards the pandemic.
While the COVID-19 pandemic has resulted in an unprecedented challenge to healthcare systems and ICU resources mainly for adult patients, the ways the pandemic affected critically ill children globally have often received less attention. Contrary to previous pandemics such as the H1N1 flu, direct COVID-19-related critical illness in paediatric age groups has remained rare. Large epidemiological studies from the US and Europe indicate that the vast majority of children infected with COVID-19 remain asymptomatic. We will discuss phenotypes of COVID-19 manifestations in critically ill children and neonates, but then focus more on a unique paediatric-specific phenomenon associated with COVID-19, namely Paediatric Inflammatory Multisystem Syndrom (PIMS-TS, or MIS-C), and highlight lessons learnt from this condition. Finally, we will explore indirect impacts of the pandemic on critically ill children, including aspects such as the dilemma of restricting parental access to acutely ill children, altered non-COVID epidemiology, socioeconomic issues, and finally, how the pandemic may change the future of paediatric research.
In order to distinguish moderate treatment effects of a treatment from no effect, randomization of large numbers of patients is required. The RECOVERY trial was set-up rapidly as the COVID-19 pandemic reached the UK to ensure that large numbers of patients from hospitals across the UK could be recruited without interfering with the clinical care of the patients while the hospitals were under significant stress. By keeping the trial procedures simple and only asking hospitals to do what was absolutely required, the RECOVERY trial randomized 10,000 patients in 8 weeks and provided robust information on three potential treatments within 3 months. The methods used in RECOVERY could and should be applied to many other diseases beyond COVID-19 and address many of the important uncertainties in patient care and population health.
A number of options are available to attendees during our break times: Room 1 (Main stream) will broadcast our first virtual Yoga Session, followed by a presentation from our premium sponsor - Linet. To finish the break we are pleased to include an important update from the Intensive Care Foundation.
You can also take the opportunity during this break to visit our Exhibition zone (under sponsorship and and exhibition) to receive your daily codeword. You can go in a daily draw to win an amazing piece of Indigenous Art. A number of networking rooms are also available to catch up with friends.
As part of our Well-Being initiatives, we invite you to join us for a quick revitalising and mindful yoga practice. This yoga session is suitable for all levels, no yoga mat required.
Remember back to a time 18 months ago when COVID was not a word you were familiar with.
When severe acute respiratory infection (SARI) meant influenza, community acquired pneumonia or perhaps if you were lucky, some really unusual type of pneumonia! We didn’t know about lockdowns, bubbles, flattening the curve or Zoom.
What do we know about SARI incidence and treatment innovations in the last year? How may SARI therapies perhaps change given our pandemic experience? What will the world post-COVID look like in terms of management of SARI and how are we studying this now?
Pneumonia remains a global healthcare challenge associated with substantial morbidity and mortality. Antimicrobial therapy is the primary intervention used by clinicians, but variable effectiveness exists which in part can be related sub-optimal dosing. To be maximally effective, antimicrobial dosing should ensure therapeutic concentrations at the site of infection, which in the context of pneumonia, is measured in the epithelial lining fluid (ELF). Of course, defining which concentration is ‘therapeutic’ is affected by the susceptibility of the pathogen to the antimicrobial (pharmacodynamics). Concentrations in the ELF for most antimicrobial are affected by typical factors like renal function and body size, as well as sickness severity, lung inflammation and presence of fibrosis from chronic pathologies like chronic obstructive airways disease. Careful interpretation of data is also important as concentration-time profiles in the lung do not match plasma and so singular time-point comparisons can provided misleading estimates of drug penetration. Available data demonstrates highly variable antimicrobial exposures in ELF, both between antimicrobials and between patients receiving the same antimicrobial. Antimicrobials considered to have consistently adequate penetration into the lung include linezolid and macrolides like azithromycin. Beta-lactams have variable penetration (e.g. meropenem ELF exposure is <5% to >200% in ventilator associated pneumonia patients). Other drugs have low and variable penetration including glycopeptides, whilst the aminoglycosides have such low penetration that they are considered not a clinical option in monotherapy. The importance of antimicrobial penetration into the lung is being recognized by pharmaceutical industry, with some drugs like ceftolozane-tazobactam now having a pneumonia-specific dose which is twice the urinary tract and intra-abdominal infection doses to account for ~50% lung penetration.
Described a mere 25 years ago, our understanding of lung ultrasound and how it can be used to inform rapid, bedside diagnosis and management of the critically ill is growing rapidly. From basic B lines to advanced techniques – this education-focused talk will, in addition to providing examples of all key lung ultrasound findings, will discuss integrating these findings, practical tips and future directions.
Interventional pulmonology techniques and procedures have become more complex over the past decade. There are a multitude of procedures for both diagnostic and therapeutic purposes available to the clinician. These range from Endobronchial Ultrasound (EBUS) for accurate diagnosis of malignant and non-malignant conditions, to Bronchial Thermoplasty for therapy in moderate to severe asthma, to stent insertion for airway obstruction or tracheo-oesophageal fistula. Not all procedures are relevant to current Intensive Care Medicine practice.
This presentation will focus on three procedures relevant to Intensive Care Medicine. Firstly, the use of endobronchial valves in the management of persistent air leaks from broncho/alveolar-pleural fistulae. This technique allows resolution of air leaks in patients on mechanical ventilation, who may not be fit for surgical intervention. This is a novel use of these devices, which were originally designed for endoscopic lung volume reduction in COPD. Secondly, the technique of cryobiopsy for diagnosis of parenchymal lung disease and the risk of pneumothorax and significant haemorrhage with this procedure. Significant haemorrhage has been described after cryobiopsy and may need ICU admission, if life threatening. The use of a bronchial blocker at the time of the procedure reduces bleeding risk. Lastly, the therapeutic modality of bronchial thermoplasty (BT) for moderate to severe asthma and the risk of exacerbation post procedure. BT requires three separate bronchoscopic procedures, three weeks apart. Patients are at risk of exacerbations of asthma up until six weeks after the last procedure. A lower FEV1 predicts the risk for post procedure hospitalisation.
Professor Anil Hormis (Rotheram NHS Trust, UK) discusses the limitations of and challenges posed by conventional intravenous sedation practice, and the potentil advantages of instead sedating intensive care patients using inhaled volatile anaesthetics. In this short talk Professor Hormis also discusses the equipment and changes to breathing circuit configuration required to safely administer inhaled volatile anaesthetics outside of the operating theatre.
This talk will review the definition, burden, and prognosis of chronic and persistent critical illness. Historically, prolonged ICU stays have been thought of as being synonymous with prolonged mechanical ventilation, which was termed “chronic critical illness”. However, many patients remain stuck in the ICU for reasons other than persistent mechanical ventilation. While some patients have persistent organ failure necessitating ICU care, other patients experience a cascade of problems, such that what keeps them in the ICU may differ substantially from what brought them to the ICU in the first place. A new syndrome of “persistent critical illness” has been defined to encompass the broad scenarios by which patients remain ICU-dependent due to ongoing illness and clinical instability that is no longer directly attributable to the original organ dysfunction prompting ICU admission. In several large-scale epidemiologic studies across multiple countries, persistent critical illness had been empirically determiend to begin around 10 days after ICU admission. This is the point at which characteristics at ICU admission (admission diagnoses and physiologic derangements) are no longer more predictive of mortality than antecedent characteristics (age, sex, chronic health status). While persistent critical illness occurs in just 5% of ICU admissions, it has a disproportionate impact on ICU resource use—accounting for nearly a third of all ICU bed-days. Furthermore, rates of persistent critical illness vary more than 3-fold across hospitals, suggesting the importance of contextual as well as patient factors in the development of persistent critical illness.
Despite emerging awareness of Post Intensive Care Syndrome (PICS), there is lack of robust evidence on optimal rehabilitation strategies for ICU survivors. The precise timing of initiation, duration, frequency (dose) of early physical rehabilitation remains unclear. Studies that focus on psychological rehabilitation of ICU survivors are sparse and show mixed benefit.
There are multiple modifiable barriers to the ongoing rehabilitation of ICU survivors in acute care hospitals. Some of the barriers to in-hospital rehabilitation include:
A) Patient factors: delirium, weakness, frailty, physiological safety
B) Knowledge and skills: knowledge of PICS; general knowledge and skills around mobilisation; inadequate training and adherence to pain, agitation and delirium guidelines
C) Environment and resources: Inadequate staffing/equipment/space/funding
D) Behavioural: Lack of mobility champions, absence of protocol/medical order for mobilisation, lack of interprofessional communication
Addressing these barriers and investing in future research related to rehabilitation strategies may have benefits for the ongoing care of ICU survivors.
Most children are surviving critical illness in highly resourced paediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development and be life-long, termed post-intensive care syndrome-paediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations.
To date, primary and secondary outcomes have been largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centres are discovering how to overcome them and are providing this service to families – sometimes specific populations - in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU.
The considerations, challenges and barriers to long-term follow-up following paediatric critical illness will be explored and current national and international approaches to research and clinical follow-up discussed.
THE USE OF PHENOMENOLOGY AND INTERPRETATIVE PHENOMENOLOGCICAL ANALYSIS TO STUDY INTENSIVE CARE PATIENTS’ EXPERIENCES AT POST-ICU DISCHARGE FOLLOW-UP: ENSURING COMMUNICATION AND EMPATHY AS THE CORNERSTONES TO GOOD CLINICAL PRACTICE
Introduction
Post Intensive Care Syndrome (PICS) describes the health problems that remain after critical illness. There is an increasing interest in the human experiences of Intensive Care Unit (ICU) patients, to ensure greater holistic care and management.
Research question What is the lived experience of patients with critical illness in the ICU?
Design Phenomenological study.
Sample The first fifteen patients referred to a post-ICU follow-up clinic.
Data collection and analysis Face-to-face interviews with Interpretative Phenomenological Analysis.
Results and methodological insights Two superordinate themes were identified. The superordinate-theme ‘I have a voice, you’re just not listening’ had three themes: ‘Patience, not predictive text’, ‘Yes, I did just say that’, and ‘Talk to the hand’. The superordinate-theme ‘Wear my shoes-empathic understanding’ had three themes: ‘Care not pity’, ‘From the minute I wake up’, and ‘Small things are massive’.
Whilst empathy and communication are often discussed as vital aspects of patient care, this study provides context and examples of how they impact everyday practice for all healthcare staff. The methodology and methods used in this study, phenomenological and IPA are ideally suited to the patient experience and will be critical in future analysis of ‘long-COVID’ patients, which are currently being studied in COVID-recovery.
The use of phenomenology and interpretative phenomenological analysis to study intensive care patients’ experiences at post-ICU discharge follow-up: ensuring communication and empathy as the cornerstones to good clinical practice
As we look beyond ICU to the impact of critical illness and intensive care therapy on survivors, we also recognise the impact on the bereaved. Complicated or difficult grief and post traumatic distress are common experiences after a bereavement in ICU. Follow up by intensive care teams can help address questions that may be barriers to grieving. Learning more about the experience of the bereaved in our units can help us improve the care we provide to dying patients and their families, and the support we provide to clinicians caring for patients.
This presentation will discuss what we know about grief after a death in ICU. The evidence for bereavement follow up will be reviewed. Guiding principles for follow up teams, which acknowledge the limitations of the evidence and the vulnerability of those followed up, will be discussed.
Fluids are one of the most common treatments administered in acute hospitalized patients. Even small differences in fluid management outcomes data can have significant effects on the healthcare system.
In this webinar Prof Rinaldo Bellomo (Professor of Intensive Care, University of Melbourne & Department of Intensive Care Austin Hospital and Royal Melbourne Hospital) presents on the ‘SWIPE’ randomised clinical trial he co-authored, sharing the rationale and data on why small volume fluid resuscitation with albumin 20% is an option for your ICU patients.
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