Symposium: "Advances in Critical Care"
The meeting started at 2pm with a welcome from the President of the section of Anaesthesia, Dr Diana Meadows who then introduced the first speaker, Dr Saxon Ridley from Norwich.
1) Sepsis and the impact of Xigris in the UK
Dr Saxon Ridley (Norfolk)
Dr Ridley spoke about the incidence of sepsis in the UK and presented some figures from the ICNARC database, which showed that severe sepsis currently had a mortality of 47%. The ‘Surviving Sepsis’ campaign aimed to reduce this mortality by 25% with the introduction of care bundles. He went on to explain the resuscitation bundle and its perceived benefits of reducing mortality, raising awareness of the problem, reducing practice variation, reducing patient length of stay and increasing teamwork. The criticisms of this approach were a reduction of clinical autonomy and some inappropriate targets. He went on to look at some new approaches in sepsis with the better understanding of the inflammatory cascade however commented that none of these had proven to be successful. However there were 5 recent advances that had improved outcome which he spoke about. They were low tidal volume ventilation with adequate PEEP, early goal directed therapy, steroid supplementation, tight glycaemic control and activated protein C. The final section of his talk was about cost effectiveness of APC and more generally of intensive care. He showed that in terms of health economics that intensive care was a very cost-effective intervention particularly in comparison to other newer and far more expensive therapies.
2) Critical care 5 years from now
Dr Jane Eddlestone (Manchester)
Dr Jane Eddleston discussed the future challenges for critical care medicine. 12m patients are admitted to hospital every year with about 60% being emergencies. 10% subsequently acquire hospital infections, which may subsequently become life threatening. The severity of illness is not very well measured on the wards and upto 40% of ITU admissions are avoidable if they had been picked up and appropriately treated earlier. Slow admission to ITU compromises outcome. The reasons for these late referrals were discussed by Dr Eddleston. Training changes in medical and nursing staff mean that they are increasingly less experienced and there appears to be widespread ignorance about physiology and pathophysiology. Trends were not always easy to see and there was poor process control in the patient pathway. The introduction of a Medical Emergency Team for post-operative ward based surgical patients in Melbourne had been shown to improve patient outcome with a significant reduction in patient mortality. The process control of critically ill patients should include the admission and discharge of patients as well as actual care when in the ITU. Dr Eddlestone felt that there should be a better understanding of what capacity each critical care service has, as there was a spectrum of what constitutes critical care service. There should be more support and rehabilitation for patients discharged from intensive care to optimise outcome. She finished by talking about the new source of funding for critical care with the development of a new tariff, which depends upon the submission of new datasets.
3) Debate: 'This House believes that Pulmonary Artery Catheters are no longer required in the Management of Critically Ill Patients'
Dr P Dark (Salford) in favour and Dr Richard Nelson (Chester) against the motion
Dr Paul Dark started his talk with a historical account of the development of the pulmonary artery catheter. He stated that there was no evidence of the clinical effectiveness of this treatment when it was introduced and there has been no evidence of its effectiveness subsequently produced which has been re-inforced by the PACman trial which showed that outcome was unaffected and there was a 10% complication rate. The only evidence for its efficacy was in early goal directed therapy in patients before they are sick enough to require intensive care, precisely the patients who do not get these devices in the UK. He pointed out that there was a move to minimally invasive devices that had far fewer complications and there would also be a cost saving. He finished by stating that this was a historical device that no longer had a use in current intensive care.
Dr Richard Nelson came to the defence of the PAFC and looked into why it had recently gone out of fashion with a review of the literature in the last 10 years. He showed the positive side of PAFCs where in early goal directed therapy and pre-optimisation, there was an improvement in outcome. There was little dispute that flow directed therapy works when used early in sick patients and the PAFC was the only device that had been proven to achieve this goal. He stated that other devices currently lack a solid critical care evidence base.
The debate was curtailed through lack of time however the motion was defeated with Dr Nelson winning the day.
4) Advances in the Management of Massive Haemorrhage – The Role of Recombinant Factor VIIa
Dr Richard Wenstone (Liverpool)
Dr Richard Wenstone firstly went through the background of the coagulation cascade and how the understanding of it had changed in recent years. He then spoke about the specific role of rFVIIa and how it helps to produce a Thrombin burst to aid haemostasis. He stressed the importance of having sufficient amounts of other clotting factors and platelets in the circulation for it to be effective as well as correcting acidaemia and hypothermia. In theory it should only work in areas of tissue damage where platelets are activated and this seems to be true in practice with few thrombotic complications with its limited use. Dr Wenstone then presented a regional audit with the widely varied patients in which it had been used.
The meeting concluded at 17.20 with a vote of thanks given by Dr Will Roberts, President of the LSA.