Critical care updates 2013 – highlights of a medical event organised in Malaysia
Syamala Ariyanchira provides an overview of the recent ‘Critical care updates 2013’ event held recently in Malaysia.
The interest in understanding the emerging trends within critical care sector was evident at the recently organised Critical Care Updates 2013 in Kuala Lumpur, Malaysia. The event was organised by Hospital Sungai Buloh (HSB) by its critical care and anaesthetic teams together with AcuBiz Consulting Sdn Bhd, The event received an overwhelming response from the medical community in Malaysia.
“Some of the emerging trends in ARDS management indicated by him include the rising awareness of good practice guidelines…”
Dr. Shanti Ratnam, the head of the department of ICU at HSB, was instrumental in bringing together a group of critical care experts from Malaysia, India, Australia, and USA as speakers to cover various topics relevant to critical care practice ranging from traumatic brain injury to antibiotic resistance.
Figure 1: The Critical Care Updates 2013 conference room
The event started with a welcome address by Dr. Shanti Ratnam, followed by a talk by Professor Charles Weiner, Dean of Perdana University, Malaysia on acute respiratory distress syndrome (ARDS) management and ventilation strategies. Some of the emerging trends in ARDS management indicated by him include the rising awareness of good practice guidelines, limiting high tidal volumes in cases of acute lung injury, strategies to prevent additional lung insults, role of conservative fluid strategy in potential reduction of mortality (dry strategy) in cases of pure ARDS, and various rescue strategies such as inverse ratio ventilation (IRV), and emerging interest in the use of surfactants in ARDS.
Dr. Rajaram Ramadoss, consultant at the Department of intensive care at Lyell McEwin Hospital, Australia, talked about acute kidney injury (AKI) in ICU. After introducing the RIFLE criteria (Risk, Injury, Failure, Loss of life, ESRD (end stage renal disease)) proposed by the Acute Dialysis Quality Initiative (ADQI) group, he defined AKI in the context of ICU based on RIFLE criteria. His talk covered various practical aspects related to AKI such as prevention, diagnosis, and renal replacement therapy (RRT). Fluid management trends in ICU for prevention of AKI based on the data from various clinical trials were discussed, where importance of early aggressive fluid resuscitation was emphasised. One of the important trends highlighted was the tendency to avoid fluid overload and synthetic colloids in patients at risk of AKI. Other preventive strategies recommended include limited exposure to nephrotoxins including various loop diuretics. Regarding diagnosis of AKI, the importance of patient history and urine microscopy and chemistry were emphasised. The talk was concluded with a detailed analysis of RRT in the case of AKI in ICU. Pros and cons of early vs late initiation of RRT were discussed based on the data from various recent clinical trials. Various modalities of RRT such as intermittent haemo dialysis (IHD), peritoneal dialysis (PD), and continuous renal replacement therapy (CRRT) were discussed with an emphasis on the clinical performance vs cost effectiveness of each platform.
“His talk covered various practical aspects related to AKI such as prevention, diagnosis, and renal replacement therapy (RRT).”
Sepsis is a leading cause of death in critically ill patients. An update on sepsis and management of septic shock were provided by Dr. B. Soundaravalli, consultant perioperative medicine, G.K.N.M Hospital, India. The talk included new trends in the diagnosis of sepsis, including the role of biomarkers, a major research focus in sepsis management since inflammatory markers such as white blood cell count (WBC) and C-reactive protein (CRP) lack specificity for bacterial infection. Procalcitonin (PCT), triggering receptor (TREM1), and cluster of differentiation-64 (CD64) are more recent biomarkers with better specificity. New diagnostic and prognostic biomarkers such as soluble urokinase plasminogen activator (suPAR), angiopoietin, and pancreatic stone protein / regenerative protein (Psp/reg) in sepsis management were also mentioned. Other topics stressed based on data from various clinical trials included emerging practices related to fluid resuscitation, control of septic focus, antibiotic selection criteria, and adjunctive therapy.
Dr. Shanti Ratnam highlighted some of the important trends in the management of severe traumatic brain injury (TBI). The development of standardized approaches based on the international guidelines was underlined as one of the major advancements in the field of TBI during the past two decades since this field lacks data based on randomized clinical trials. Optimal TBI management based on the guidelines in specialized neurotrauma centres with neurosurgical and neurocritical care support can significantly improve clinical outcomes.
Limiting secondary brain injury in patients with severe TBI was stressed as the principal focus of critical care management. She also provided case studies related to various aspects of TBI including intracranial pressure management (ICP), maintenance of cerebral perfusion, optimization of oxygenation, management of blood pressure, temperature, glucose, seizures, and other potential secondary brain insults.
Dr. Santhi Raja, consultant at San Leandro Hospital, USA turned the focus of the event to the safe transport of critically ill patients and stressed some of the important factors to be concerned about during pre-hospital, intra-hospital and inter-hospital transport. She discussed in detail about the physiological changes that can happen during transport and good practices that can help to achieve desirable clinical outcomes. She also compared transport practices of critically ill patients in USA, Australia and India. Topics discussed included high altitude transport concerns, transport vehicle requirements, equipment selection in the transport vehicle, and best practices by transporting team while moving a patient.
“Dr. Shanti Ratnam highlighted some of the important trends in the management of severe traumatic brain injury (TBI).”
Dr. Suresh Kumar, Consultant Infectious Diseases at HSB, talked about antibiotics for multi-drug resistant organisms (MRO) and nosocomial infections. The talk focused on specific antibiotic treatments where infecting organisms have been identified. MROs discussed included extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumonia, acinetobacter, pseudomonas, methicilln- resistant Staphylococcus aureus (MRSA), and carbapenem-resistant enterobacteriaceae (CRE). Recent clinical studies focusing on the effect of various antibiotic treatment approaches to handle these infections in ICU patients were highlighted and recommendations based on the data from these studies were provided during the talk. Concerns in antibiotic use and recent guidelines and acceptable practices with respect to treatment with antibiotics were discussed. Other topics handled in detail include combination treatment vs. single and recommended prescribing practices while using antibiotics such as colistin, tigecycline, and vancomycin.
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What are the emerging trends in ARDS management?