Having attended last year’s Symposium and found it extremely insightful, I was keen to attend this year’s expanded 10th anniversary meeting. As always, the faculty list contained some of the most renowned names in critical care. With a bigger meeting and parallel scientific sessions has come a bigger venue. The Palace Hotel hosted the meeting this year, with the grand architecture being a reminder of the role of Manchester at the heart of the industrial revolution. It was fascinating and useful to hear both the general consensus and occasionally contrary views about current intensive care practice. It was invaluable for a trainee learning the specialty to hear the latest thinking in a number of areas in which the textbooks are already out of date. A new innovation for this year was the ability to interact via twitter which many delegates took advantage of.
The plenary session was opened by Prof Jean-Louis Vincent leading a tribute to the late Prof Dan Traber, describing his tremendous contribution to critical care research. Dr Steven Streat from New Zealand gave us an insight into ‘21st century thinking’, arguing that many interventions persist by the perceived need to do something. He questioned how evidence is interpreted and that it is done under the influence of our pre-existing beliefs. For example, the SAFE study has been interpreted as supporting differing fluid strategies. The fluid you receive for resuscitation depends on where you are in the world. The fact that albumin is free to Australian hospitals is not unrelated to its high frequency of use there.
Dr Manu Malbrain followed, dissecting the Surviving Sepsis guidelines with regards to fluid resuscitation, particularly with regards to the use of a CVP target. He argued that chasing a CVP often leads to over-administration of fluid and that static filling pressures are not useful in predicting fluid responsiveness. In a whistlestop review of cardiac output monitoring (with over 120 slides in 15 minutes!) we learned of the utility of volumetric techniques. Dr Farhad Kapadia continued the theme, arguing that ‘less is more in improving critical care outcomes’. Since we do not fully understand the body’s adaptive response to illness, he suggests that we should let it get on and do it. There is little evidence for adrenaline in CPR. High levels of oxygen increase mortality post cardiac arrest and in COPD yet we seem unable to give it up. He argues that we need to change beliefs. The fact that most trials in critical care have negative results underline that it often more appropriate to do nothing rather than something.
Prof Vincent then outlined the ICON audit which looked at the care of 10069 patients in 84 countries, demonstrating differences in age, outcome and the use of organ support. A smaller proportion of patients on intensive care units are being ventilated than previously.
Dr Paul Barach from the United States then talked about human factors in preventing adverse events in intensive care. He argued that the high rate of avoidable adverse events in intensive care units, possibly occurring in up to 35% of patients, represents a form of ‘normalised deviance’ by which we accept poor care. The importance of process to outcome was underlined by fact that mortality is 36% higher in the United States if you have surgery on a Thursday or Friday compared to Monday to Wednesday. The processes of high reliability industries such as nuclear have a thousand times more reliability than intensive care. A sobering thought.
I decided to attend the ventilation session next with Prof Kathy Rowan presenting data which suggested that there is a clear relationship between the volume of patients ventilated on a unit and outcome. This potentially has implications for policy. Dr Richard Beale then presented a review of high frequency oscillation ventilation since the disappointing results of the OSCAR and OSCILLATE trials. He suggested that the higher mortality seen with oscillation in OSCILLATE may be due to the more aggressive ventilation strategy with higher pressures used. Dr Beale suggested that oscillation may still have a place in expert hands. Prof David Linton then explained adaptive support ventilation, a new form of ‘intelligent’ ventilation which automatically detects whether patients are ready to wean and then does so automatically. It may be coming to an ICU near you.
Lunch followed and I joined 21 others in presenting a poster to the judges. This is a new departure for this meeting and gives an excellent opportunity for trainees to present at a major meeting and have their abstracts published in an international journal. I hope this innovation continues in years to come.
The afternoon brought a session on haemodynamic monitoring with Prof Michel Slama outlining the role of echocardiography in sepsis. Prof Azriel Perel argued against protocolised haemodynamic management in septic shock, with a critique of the Rivers study, again arguing that CVP is not a useful parameter by which to guide resuscitation. The message is that protocolised care should leave room for therapeutic judgement.
After more coffee, Dr Kuiper from the Netherlands told us of the difficulties of prognostication post cardiac arrest, particularly with the advent of therapeutic hypothermia. Prof Walsh from Edinburgh discussed transfusion thresholds. The conclusion seems to be that 7 g/dl is acceptable for most people but in acute coronary syndrome 8 g/dl may be more appropriate. More work is however needed.
A workshop on fluids then followed. Prof Teboul reminded us of the fact that a fluid challenge cannot (by definition) be used to predict fluid responsiveness and is only successful in 50%. Dr Malbrain explained the concept of ‘de-resuscitation’. He underlined its importance with the fact that on average, non-survivors are 8 litres positive by the end of their first week on ICU compared to survivors who are only 3 litres positive. Dr Roop Kishen explained the deleterious metabolic effects of chloride rich fluids. This brought to an end the first day.
I particularly enjoyed the lung ultrasound workshop with Dr Ranier Gatz and Marek Nalos the next morning. After some case presentations, it was very useful to be supervised actually doing some hands on scanning. I will certainly be more comfortable in using this technique in clinical practice in future.
An update on neuro-critical care provided an insight into the future. Prof David Crippen described nano-robots which he believes will be used to clear subarachnoid haemorrhage in years to come. He also believes that organs may be preserved by cryogenics. Two intriguing prospects for the future. Prof Joe Lex cast a sceptical eye on the evidence for thrombolysis in acute stroke. Prof Bala Venkatesh outlined the possible neuro-protective effects of ketones in brain injury. Prof Polderman reviewed the maintenance of homeostasis in brain injured patients. This included a striking slide showing large areas of brain which were hypoperfused after hyperventilation in a brain injured patient. Tom Bleck then provided an update on the evidence on treatment of status epilepticus.
After hearing Dr Orton from Oldham discuss the mechanism of propofol and its effect on the endocannabinoid system, I was keen to head to the education session. Dr Anna Batchelor explained the changes to the training system in intensive care medicine in the UK. It was useful to hear the background to the changes and the future direction. Trainees were very keen to ask her about what will be happening in the future and the questions continued into the coffee break. As a contrast we heard about ICU training in Brazil from Dr Fredrico Bruzzi de Carvalho.
Prof Mervyn Singer from University College London then took to the stage to decry the new religion of ‘bundlism’. He added to the criticism of the basis of some of the Surviving Sepsis guidleines. He also critiqued the evidence for the ventilator acquired pneumonia bundle used in the UK. He advised that ‘guidelines should be guidelines not rules written in stone’. He argued the case for what he described as EBID, evidence based individiualised decision making. In the last session, we learned that hypothermia is feasible in awake patients with Prof Polderman. Prof Fang Gao Smith explained the evidence behind the unpalatable idea of enteral faecal infusion for recurrent clostridium difficile infection, however there is no evidence yet for probiotics. Associate Prof Don Chalfin argued the case for dedicated intensivists in ICU and Prof Mitch Fink described organisational models for critical care services. Prof Mervyn Singer then talked about ‘suspended animation’ and explained that sulphide is a treatment of potential in ischaemia-reperfusion injuries, with the effect of decreasing metabolism.
To summarise, key themes included the importance of thinking about interventions rather than following bundles or protocols without questioning, and criticism of the use of CVP to guide fluid resuscitation. I found it valuable to reflect that sometimes, the most appropriate treatment may be to do nothing rather than intervene in a way which could potentially harm the patient. This includes blindly giving fluid. I left feeling thoroughly up to date on many of the latest topics. Having recently sat the FFICM examination, I would recommend this meeting to anyone planning to sit an examination in intensive care. Examiners expect more up to date knowledge than that in found text books and attending a conference such as this would be ideal preparation. Perhaps a specific session for an exam knowledge update for trainees could be considered for future years. Trainees will find this meeting beneficial for exam preparation, the opportunity to present an abstract, as well being inspired by key thinkers across intensive care medicine. It is also a chance to be able to meet and socialise with other trainees. I would like to thank Dr Veerappan for organising the event and I am looking forward to next year’s Symposium.
Redmond Tully, Specialty Registrar in Anaesthesia and Intensive Care Medicine, Manchester, United Kingdom