From CodaZero Live, Steve Morgan talks to us about temporary mechanical circulatory support in cardiogenic shock. Steve gives an example of a patient with refractory cardiogenic shock, who hasn’t responded to pharmacological support. So, how do we go about choosing between temporary circulatory support options? First, Steve acknowledges that critical care echocardiography is central. Additionally, he discusses the use of pulmonary artery catheters.  Finally, Steve hopes that future Randomised Control Trials might contribute to a better evidence base to guide the use of these supports in specific patients. Finally, for more, head to our podcast page #CodaPodcast 

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Impella and modern mechanical support

Brain injury outcomes and predictors by Kiran Lele Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources. However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task. Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome. Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models. There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases. We end with three brief vignettes which highlight the fraught nature of long term outcome prediction. For more head to, https://codachange.org/podcasts/ 

Brain injury outcomes and predictors

In this podcast, Celia Bradford talks to Bing Brotohusodo about a challenging time in his life. Early in 2020, Bing contracted COVID-19. This resulted in a two-month hospital stay and admission to the ICU. Celia was one of Bing's physicians and together, they reflect on Bing's time in hospital and his recovery. Bing was as a helpful patient. So much so, that he was able to prone himself! However, Celia recalls how challenging it was treating Covid in those early days. Staff were desperately trying to work out what Covid was and how best to treat it. The question of "are we doing the right thing?" was always in the back of people's minds. Furthermore, this was exacerbated by the confusion of multiple treatments being promoted in the media. There were countless opinions about how Covid should be treated. Information was flowing fast, making it challenging to discern what the best way forward was. Celia and Bing reflect on Bing's time in ICU and his post-COVID recovery. Tune in to a podcast from #CodaZero Live on a patient's perspective of COVID-19. For more head to https://codachange.org/podcasts/ 

COVID-19: A patient's experience

In this second episode on vascular access, the team from the Australian Vascular Access Society (AVAS) discuss vessel assessment with RaCeVa and RaPeVa as well as the use of Micropuncture and establishing optimal catheter tip position.  Before puncturing a vessel for vascular access it is important to: Trace the anatomy of the vascular pathway for aberrancy Ensure that the vessel calibre is suitable for the chosen catheter Ensure no obstruction with thrombus or occlusion Moreover, it is vital that the catheter doesn't occupy more than one-third of the diameter of the vessel. This will significantly reduce venous blood flow and increase the risk of catheter-related thrombosis. For PICC line insertion the arm can be divided into three zones to select an optimal vessel puncture site. The brachial fossa region is a "Red - no Go" zone, the mid-arm is the "Green - Optimal" zone and the proximal third of the arm is a "Yellow - Axillary" zone. When inserting a line, the catheter tip should be at the cavoatrial junction approximately 3-5cm below the carina on a chest X-ray. The use of a navigation system like catheter tip ECG (intracavitary ECG) is extremely accurate. It is often still useful in patients in atrial fibrillation but more difficult for patients' with paced rhythms. For more like this, head to codachange.org/podcasts/ 

Vascular Access: RaCeVa, RaPeVa, Micropuncture, Tip position

The prehospital management of patients with moderate and severe TBI can be complex.  In this podcast, Marty Nichols talks us through managing patients with TBI in a prehospital environment. This involves avoiding hypoxia and hypotension, ensuring a safe transportation and getting to the right treatment centre the first time.  Notably, due to the nature of the accident, patients with a severe head injury also often present with other injuries. Managing multiple injuries at the same time has implications for how TBI's are managed and treated in prehospital settings. First and foremost, clinician's should prioritise the prevention of hypoxia and hypotension when managing TBI patients. This includes effective airway management, however, airway management and the prevention of hypotension present some of the greatest challenges to clinicians.  Marty discusses the challenges in treating patients with TBI in prehospital environments. Furthermore, he discusses the processes in place which help to ensure that these patients have the best possible outcomes.  For more head to https://codachange.org/podcasts/ 

Prehospital resuscitation of TBI

In this podcast, Ed Litton summarises 10 clinical trials in 10 minutes. Ed invites you to choose, based on the title alone, whether the findings were consistent with, or contrary to, the study hypothesis. Ed discusses 10 non-covid clinical trials, all published in 2020. Notably, all of these were published in the New England Journal, JAMA or Lancet and had important findings. The following hypothesises are discussed: 10. Firstly, the impact of resident physician schedules and the affect on patient safety. 9. Early initiation of renal replacement therapy and whether this improved outcomes for Acute Kidney Injury. 8. Does the implementation of early ECMO improve outcomes for patients with refractory VF and out of hospital cardiac arrest? 7. Then, can a machine learning algorithm reduce hypotensive severity? 6. In mechanically ventilated patients, is an approach of non sedation superior to light sedation? 5. Moreover, in patients who are ready for decannulation, does timing based on the suctioning frequency improve outcomes? 4. Does administering high dose tranexamic acid in patients with upper or lower GI bleeds decrease mortality? 3. Next, does a decreased exposure to vasopressors improve outcomes in older critically ill patients? 2. Will starting Dexmedetomidine at the time of cardiac surgery reduce AF and delirium in patients? 1. Also, will being conservative with oxygen in patients with ARDS improve outcomes? Tune in to a talk by Ed Litton as he shares the top 10 papers of 2020 in 10 minutes. Finally, for more podcasts head to https://codachange.org/podcasts/ 

Top 10 Critical Care Papers of 2020

In this podcast, Claire discusses the role of clinician communication and its impact on acute pain management. Claire explains how pain management outcomes can be optimised by enhancing patient expectations of benefit via patient-provider communication. Firstly, what we say to patients matters. Secondly, how we say it also matters. Pain is a complex phenomenon and managing expectations of pain and people’s experience of empathy is crucial. As healthcare professionals, we see multiple patients and are often run off our feet, but, as the studies clearly demonstrate… communication matters. And it matters a lot in pain management. This presentation shares research demonstrating the impact of clinician communication. Specifically, this includes how clinicians' talk about pain and pain management. Claire discusses the importance of patients' experience of pain, the effectiveness of pain management and patients' treatment outcomes. From CodaZero Live, tune in to a fascinating discussion on the importance of communication.  For more like this, head to https://codachange.org/podcasts/ 

The importance of communication in pain management

From CodaZero Live, Alex Rowell reviews the available advanced liver supports for patients with acute liver failure. Artificial supports for the liver are quite complex and difficult. This is largely due to the liver's complex function. Some of the advanced liver supports include CVVHDF, Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and high volume plasma exchange. In this podcast, Alex takes us through the research and evidence for these supports and shares some guidance on when they should be used.  CVVHDF is familiar and effective but we need to remember to use it early with acute liver failure patients. Furthermore, Molecular Adsorbent Recirculating System (MARS) is widely studied but unfortunately not available in all places. Single Pass Albumin Dialysis (SPAD) is easily implemented. Although there is less evidence on SPAD, it is generally agreed to be an effective support. Unfortunately, there are no mortality benefits in any of these supports. They are however, useful tools in bridging to transplant. For more head to https://codachange.org/podcasts/ 

Advanced support of Acute Liver Injury

 In this podcast, Ruth provides a summary of surgical considerations when managing an injured spine patient. She covers imaging considerations, indications for surgery and challenges to delivering excellent surgical care.   Ruth shares a story of one of the most severely injured patients she has ever looked after. A 78 year old woman came into a trauma centre having been driven over by a 4WD... twice.   She had a fractured lower limb, significant chest trauma, a significantly deformed torso, she could not feel or move her legs (other than wiggle her toes slightly) and she had tyre marks on her torso...    When looking at her injuries, it was clear that she had a significant group of chest injuries. This is an important reminder that spine trauma happens in the context of multi trauma. This subsequently impacts every step of the care process including surgical planning and management.    The objective from the outset is to try and get patients like this to theatre as quickly as possible but there are surgical considerations to take in to account.    Tune in to an incredible story as Ruth shares that the key to success is simple things done well, done consistently and in a team environment.  For more head to  https://codachange.org/podcasts/ 

Surgical considerations in the injured spine patient

 Chris provides a brief update on some of the postulated underlying mechanisms involved in subarachnoid haemorrhage associated brain injury. These mechanisms provide hints to future therapeutic targets that will hopefully expand our currently limited repertoire of options. Subarachnoid haemorrhage is a catastrophic type of stroke. Subarachnoid haemorrhage represents only 5% of the total stroke burden. Notably however, as it is most common in people aged 40-60 years, it has a disproportionate effect from a personal, social and economic perspective. Subarachnoid haemorrhage classically presents as a thunder clap headache and loss of consciousness. Unfortunately, it is associated with high morbidity and mortality rates. There is limited research in this area and there is significant opportunity to improve the way that we manage these cases.  The key is understanding the link between early brain injury and why we develop delayed cerebral ischemia. How can we stop this from happening? How can we better understand why good brains go bad? From #CodaZero Live, Christopher Andersen provides an update on delayed cerebral ischaemia. Join Chris as he looks for future treatment options through the mechanism of brain injury in subarachnoid haemorrhage. For more like this, head to our podcast page. #CodaPodcast 

Update on delayed cerebral ischaemia

 TBI Management: Beyond the Resus Room by Andrew Chow In this podcast, Andrew Chow highlights the latest evidence for TBI. Andrew shares some clinical pearls for TBI management & highlights a future direction for the management of patients with a traumatic brain injury. Studies have shown that the demographic of TBI patients has shifted. We are now seeing an increase in the number of elderly patients with a TBI injury that need intensive care admission.  Andrew suggests that with this change in demographic, we need to consider different injury patterns and treatment protocols. Andrew provides a summary of the latest evidence impacting intensive care management of patients with TBI. He shares some clinical pearls and provides a brief run through of multi-modal advanced neuro monitoring. One thing is for sure and that is that our knowledge of TBI is still growing. The future of TBI management is evolving and Andrew predicts that it will be individualised, patient centric and involve multi-modal monitoring. For more like this, head to our podcast page. #CodaPodcast   

TBI Management: Beyond the Resus Room

 From #CodaZero Live, Behny explains the importance of Echo and lists some of the ways in which Echo can help us during a cardiac arrest. It is more than we think!  Echo is a quick, easy and simple tool, making it invaluable in many situations including cardiac arrests.   It is a bedside test that is non invasive and painless for the patient. It is easily taught to any doctor or nurse and is performed in real time at the bedside. It can be used to guide and inform management and treatment, so why isn't everyone embracing Echo?   Behny challenges us to consider another bedside tool which compares to the effectiveness and usefulness of Echo.    Moreover, in the chaos of cardiac arrests, Echo can help to exclude some of the 4Hs & 4Ts. It can help to check the rhythm, check the quality of compressions and assess for post-resuscitation care. It is an invaluable tool in managing a patient suffering cardiac arrest.    Behny suggests that the focused 2D echo is our generations stethoscope. We need to open our minds and embrace the capabilities of Echo and challenge each other to learn how to effectively utilise this tool in times that matter.  Tune in to a fascinating podcast by Behny Samadi on the value of Echo in Cardiac Arrest.  For more like this, head to https://codachange.org/podcasts/ 

Echo in Cardiac Arrest

Updates in pain management by Gavin Pattullo Opioids are often a mainstay of therapy in trauma pain, though they are in turn the cause of much trauma. For every 4000 Australians prescribed an opioid there will be one death in the community as a result. In-patients similarly have greater risk of harm when their analgesia is opioid based. This presentation will focus on some of the valuable lessons learnt in pain management resulting from the opioid crisis. These include: Our need to differentiate clinically between pain and nociception. Pain - the affective unpleasant experience - is assessed by clinicians enquiring with the use of the words: coping, bothersomeness and troubling. While nociception is focussed on asking about physical feelings and sensations. Profound levels of nociception and the potential to lead to reports of significant pain, a major feature of trauma patients, requires firstly a focus on the two most effective anti-nociceptive strategies of neural blockade and NSAIDs/COX-2 inhibitors before introducing less effective strategies. Pain, the affective distressing unpleasant experience, when present with or without the use of anti-nociceptive strategies has historically been managed solely with biological strategies of opioids and adjuvant agents.  An increasing focus in clinical practice on non-pharmacological strategies to manage pain, including placebo enhancing communication strategies and message framing. Avoidance of over-reliance on pain scores. Clinicians are too often misled and poor decisions are made when the robustness of pain scores is over-relied upon. Pain scores can be useful provided there is clear understanding in both the enquirer and the patient of whether the question is relating to the level of nociception or pain being experienced. Ensuring optimal effectiveness of the opioid avoiding strategy of neural blockade. Four clinical assessment endpoints indicate effectiveness of neural blockade: presence of Dynamic pain relief, Analgesia, Sensory anaesthesia and Opioid sparing/elimination (DASO). For more head to: codachange.org/podcasts/

Updates in pain management

In this podcast, Ken Sakurai provides an update on the recent RCTs for Vitamin C in Sepsis. The battle against sepsis continues, with Vitamin C the most recent weapon in our arsenal. Since Prof. Marik’s 2017 trial on metabolic resuscitation, there has been renewed interest in the use of vitamin C. Ken reviews the rationale and pre-clinical evidence for Vitamin C use in treatments, as well as the most recent RCTs for Vitamin C in Sepsis. For more head to: codachange.org/podcasts

Vitamin C: fact or fiction?

Oli covers the initial management of patients with traumatic cervical spinal cord injury. He covers the neurological assessment – how and why we do the ASIA or ISNCSCI Exam and why it matters. It’s not always straight forward, but getting a motor and sensory level and determining if a patient has perianal sensation and voluntary anal contraction can be really helpful prognostically. The importance of avoiding hypoxia, including ways to manage an airway in this context are then discussed. Oli then talks blood pressure targets – still a controversial area, but aiming for a MAP > 85 mmHg may really help. Hypotension definitely doesn’t help. Timing of surgery is another hot topic in acute SCI. Low quality evidence suggests surgery in 

Acute Spinal Cord Injury: What Matters

Talks recorded live at the Social Media and Critical Care conferences. For more info go to smacc.net.au

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