Month: May 2018

May 15, 2018

H&R2018 Keynote Lecture: Re-Defining Sepsis by Lawrence Lynn. #FOAMed, #FOAMcc

Lawrence’s work on sepsis analysis is truly groundbreaking. To put this in perspective, one has to recognize that sepsis is an exceedingly heterogeneous disease that, once upon a time, and for good reasons, an arbitrary definition was formulated. This, however, does not reflect sepsis adequately, and needs to change with observational data, as this has tremendous implications in therapeutics research.

Lawrence’s efforts have resulted in data systems revealing a number of different patterns of sepsis, with clear differences in physiologic effects or responses. This may explain why so many failed therapies for sepsis have occurred. It is entirely plausible that some of these therapies may have effects in some of these phenotypes of sepsis but get lost in the statistical mix.

Love to answer any questions anyone may have, and Lawrence will certainly chime in on the discussion!

cheers

Philippe

 

 

 

May 9, 2018

CCUS Institute POCUS & Resuscitationist Mini-Fellowship: 2022 Update!

So over the last couple of years, the POCUS Mini-Fellowships have been slowly but steadily morphing into POCUS-Resus training.  With POCUS essentially critical in all aspects in resus, including venous congestion assessment, ventilation, diagnostics, it is a natural extension to blend the exchange into many of the other tools that we use, including discussions around fluids choices, pressor choices, monitoring using NIRS tissue oximetry, ETCO2, and overall resuscitation strategies. Of course, we will also cover VExUS as it has become an important POCUS tool, not only for the resuscitationist gauging his fluid management, but also for any clinician dealing with patients with heart failure and renal failure.

Some structured workshops can include percutaneous pigtail insertion, vascular access phantom practice and both surgical and percutaneous surgical airway manikin practice, depending on participants’ choice.

We have recently expanded with the addition of Dr. Philippe St-Arnaud, ER and CC doc and EDE (Emergency Department Echography) Instructor extraordinaire, who will increase our availability – which had been fairly limited – apologies to those whom we could not accommodate due to scheduling reasons.

This is an excellent complement to an RLA (I’m part of that faculty) or ULA fellowship, to bring a real clinical experience into the mix.

Of course, if you are a canadian trainee/resident you can get a whole month of this for free by doing an ICU elective at Santa Cabrini Hospital (foreign trainees are also welcome but more hoops to jump thru!).

Tuition (Updated 2022)

Montreal Mini-Fellowships: 600$ CAN / 500$ USD per day for 1 physician, 400$ CAN / 350$ USD per person per day for additional days, and 400$ CAN / 350$ USD per person per day for a 2-3 physician group (maximum)

Toronto Mini-Fellowships: 800$ per half day (4h).

100% refundable until you start. Even if you don’t show up. Really. We’re not in it for the business. We get to go home earlier if you don’t come.

For more details and registration information see here.

And here is some of the most recent feedback from the fellows:

Anyway, I wanted to say thank you again. You have inspired our group to continue to move POCUS into our clinical practice; we have started a fluid management algorithm in our observation unit, and hoping that the soon-to-be-added ButterflyIQ to the unit will improve its utilization. Over the last few years, we have caught a few myocarditis cases and new CHF cases initially placed in observation as “influenza,” managed hundreds of CHF cases, and had a handful of +FAST exams in our ED that we were not quite expecting (in fact, having one that was just texted to me from a co-worker is what prompted this email!).   Our POCUS program is still in its infancy, but I think the horse is out of the barn at this point. On behalf of all of our patients that we will see, thank you.

Additionally, I have gone on to co-direct a sono-wars type event at our national physician assistant conference (AAPA), for PA students. At the inaugural event, we had free workshops and a competition that included 200 student learners, representing about 30% of PA programs from all over the country. We opened a huge door for PA programs to start implementing POCUS longitudinally within their curriculum. We received amazing feedback on the program, and are hoping to publish results soon (currently with journal editors)… 

I am excited to pay forward my debts to those that have helped me.  You not only helped me, but generations of PA’s for years to come. Thank you so much for your time and commitment to excellence. What you do matters; please keep running the mini-fellowship! Patrick Bafuma EM PA @EMinFocus, Hudson Valley, NY, USA. 2017.

        This review is for the CCUS Institute Bedside Ultrasound (US) Mini-Fellowship. I was fortunate to do the mini-fellowship after the Hospitalist & Resuscitationist conference, and I was able to put into practice various techniques that we learned. Dr. Rola was a pleasure to work with and was well-versed with the latest US and free online access meducation (FOAM). The atmosphere was conducive to learning, and we picked up an ultrasound almost immediately and used it extensively through each day. We used various US machines and were able to get a good feel for all of them. My US experience before the mini-fellowship had been a two-day introductory course with healthy medical students as volunteers. At the mini-fellowship, being able to learn on actual critically ill patients was illuminating and helped cement what I had learned. We also went over relatively new bedside techniques such as point-of-care trans-cranial doppler (TCD) and optic nerve US (ONSD). Overall, the experience was well worth the 2800 mile trip, and I would enthusiastically recommend it to anyone that is interested in learning practical applications of US. – Dr. Pranay Parikh, Los Angeles, USA. 2018.

Recently I went and studied with Philippe in Montreal. I was really impressed with how seamlessly ultrasound was used in the physical exam for each one of his patients without any loss in time and often a gain in clinical information that I doubt we would have had without the ultrasound. Philippe’s ability to teach was also amazing as we worked on some very interesting concepts like portal vein pulsatility, hepatic vein and renal doppler for fluid stop points. He definitely exemplified how facile one could become with ultrasound with dedicated practice. I very much enjoyed my time and believe I learned a lot that could be used immediately at the bedside. Thanks! Dr. Joe Quinn, EM/IM/CC, Vidant Medical Center, East Carolina University, 2018.

So join us for a few days of intense, real clinical learning.

cheers,

Philippe

May 2, 2018

Petition to retire the surviving sepsis campaign guidelines. A #FOAMed Movement.

Hello to all. Below is a coordinated effort from many of us to repeal the un-physiological and sub-optimal recommendations of the SSC Guidelines. Although potentially helpful in certain cases and situations where expertise is lacking, the consequences of mandating such protocols across the board is worrisome. Please consider the issue and join us.
Philippe

Friends,

Concern regarding the Surviving Sepsis Campaign (SSC) guidelines dates back to their inception.  Guideline development was sponsored by Eli Lilly and Edwards Life Sciences as part of a commercial marketing campaign (1).  Throughout its history, the SSC has a track record of conflicts of interest, making strong recommendations based on weak evidence, and being poorly responsive to new evidence (2-6).

The original backbone of the guidelines was a single-center trial by Rivers defining a protocol for early goal-directed therapy (7).  Even after key elements of the Rivers protocol were disproven, the SSC continued to recommend them.  For example, SSC continued to recommend the use of central venous pressure and mixed venous oxygen saturation after the emergence of evidence that they were nonbeneficial (including the PROCESS and ARISE trials).  These interventions eventually fell out of favor, despite the slow response of SSC that delayed knowledge translation.

SSC has been sponsored by Eli Lilly, manufacturer of Activated Protein C.  The guidelines continued recommending Activated Protein C until it was pulled from international markets in 2011.  For example, the 2008 Guidelines recommended this, despite ongoing controversy and the emergence of neutral trials at that time (8,9).  Notably, 11 of 24 guideline authors had financial conflicts of interest with Eli Lilly (10).

The Infectious Disease Society of America (IDSA) refused to endorse the SSC because of a suboptimal rating system and industry sponsorship (1).  The IDSA has enormous experience in treating infection and creating guidelines.  Septic patients deserve a set of guidelines that meet the IDSA standards.

Guidelines should summarize evidence and provide recommendations to clinicians.  Unfortunately, the SSC doesn’t seem to trust clinicians to exercise judgement.  The guidelines infantilize clinicians by prescribing a rigid set of bundles which mandate specific interventions within fixed time frames (example above)(10).  These recommendations are mostly arbitrary and unsupported by evidence (11,12).  Nonetheless, they have been adopted by the Centers for Medicare & Medicaid Services as a core measure (SEP-1).  This pressures physicians to administer treatments despite their best medical judgment (e.g. fluid bolus for a patient with clinically obvious volume overload).

We have attempted to discuss these issues with the SSC in a variety of forums, ranging from personal communications to formal publications (13-15).  We have tried to illuminate deficiencies in the SSC bundles and the consequent SEP-1 core measures.  Our arguments have fallen on deaf ears.

We have waited patiently for years in hopes that the guidelines would improve, but they have not.  The 2018 SSC update is actually worse than prior guidelines, requiring the initiation of antibiotics and 30 cc/kg fluid bolus within merely sixty minutes of emergency department triage (16).  These recommendations are arbitrary and dangerous.  They will likely cause hasty management decisions, inappropriate fluid administration, and indiscriminate use of broad-spectrum antibiotics.  We have been down this path before with other guidelines that required antibiotics for pneumonia within four hours, a recommendation that harmed patients and was eventually withdrawn (17).

It is increasingly clear that the SSC guidelines are an impediment to providing the best possible care to our septic patients.  The rigid framework mandated by SSC doesn’t help experienced clinicians provide tailored therapy to their patients.  Furthermore, the hegemony of these guidelines prevents other societies from developing better guidelines.

We are therefore petitioning for the retirement of the SSC guidelines.  In its place, we would call for the development of separate sepsis guidelines by the United States, Europe, ANZICS, and likely other locales as well.  There has been a monopoly on sepsis guidelines for too long, leading to stagnation and dogmatism.  We would hope that these new guidelines are written by collaborations of the appropriate professional societies, based on the highest evidentiary standards.  The existence of several competing sepsis guidelines could promote a diversity of opinions, regional adaptation, and flexible thinking about different approaches to sepsis.

We are disseminating an international petition that will allow clinicians to express their displeasure and concern over these guidelines.  If you believe that our septic patients deserve more evidence-based guidelines, please stand with us.

Sincerely, 

Scott Aberegg MD MPH

Jennifer Beck-Esmay MD

Steven Carroll DO MEd

Joshua Farkas MD

Jon-Emile Kenny MD

Alex Koyfman MD

Michelle Lin MD

Brit Long MD

Manu Malbrain MD PhD

Paul Marik MD

Ken Milne MD

Justin Morgenstern MD

Segun Olusanya MD

Salim Rezaie MD

Philippe Rola MD

Manpreet Singh MD

Rory Speigel MD

Reuben Strayer MD

Anand Swaminathan MD

Adam Thomas MD

Scott Weingart MD

Lauren Westafer, MD

References
  1. Eichacker PQ, Natanson C, Danner RL. Surviving Sepsis – Practice guidelines, marketing campaigns, and Eli Lilly.  New England Journal of Medicine  2006; 16: 1640-1642.
  2. Pepper DJ, Jaswal D, Sun J, Welsch J, Natanson C, Eichacker PQ. Evidence underpinning the Centers for Medicare & Medicaid Services’ Severe Sepsis and Septic Shock Management Bundle (SEP-1): A systematic review.  Annals of Internal Medicine 2018; 168: 558-568.
  3. Finfer S. The Surviving Sepsis Campaign:  Robust evaluation and high-quality primary research is still needed.  Intensive Care Medicine  2010; 36:  187-189.
  4. Salluh JIF, Bozza PT, Bozza FA. Surviving sepsis campaign:  A critical reappraisal.  Shock 2008; 30: 70-72.
  5. Eichacker PQ, Natanson C, Danner RL. Separating practice guidelines from pharmaceutical marketing.  Critical Care Medicine 2007; 35:  2877-2878.
  6. Hicks P, Cooper DJ, Webb S, Myburgh J, Sppelt I, Peake S, Joyce C, Stephens D, Turner A, French C, Hart G, Jenkins I, Burrell A.The Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008.  An assessment by the Australian and New Zealand Intensive Care Society.  Anaesthesia and Intensive Care 2008; 36: 149-151.
  7. Rivers ME et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock.  New England Journal of Medicine 2001; 345: 1368-1377.
  8. Wenzel RP, Edmond MB. Septic shock – Evaluating another failed treatment.  New England Journal of Medicine 2012; 366: 2122-2124.
  9. Savel RH, Munro CL. Evidence-based backlash:  The tale of drotrecogin alfa.  American Journal of Critical Care  2012; 21: 81-83.
  10. Dellinger RP, Levy MM, Carlet JM et al. Surviving sepsis campaign:  International guidelines for management of severe sepsis and septic shock:    Intensive Care Medicine 2008; 34:  17-60.
  11. Allison MG, Schenkel SM. SEP-1: A sepsis measure in need of resuscitation?  Annals of Emergency Medicine 2018; 71: 18-20.
  12. Barochia AV, Xizhong C, Eichacker PQ. The Surviving Sepsis Campaign’s revised sepsis bundles.  Current Infectious Disease Reports 2013; 15: 385-393.
  13. Marik PE, Malbrain MLNG. The SEP-1 quality mandate may be harmful: How to drown a patient with 30 ml per kg fluid! Anesthesiology and Intensive Therapy 2017; 49(5) 323-328.
  14. Faust JS, Weingart SD. The past, present, and future of the centers for Medicare and Medicaid Services quality measure SEP-1:  The early management bundle for severe sepsis/septic shock.  Emergency Medicine Clinics of North America 2017; 35: 219-231.
  15. Marik PE. Surviving sepsis:  going beyond the guidelines.  Annals of Intensive Care 2011; 1: 17.
  16. Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle:  2018 update. Intensive Care Medicine. Electronic publication ahead of print, PMID 29675566.
  17. Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule.  Chest 2007; 131: 1865-1869.