Discover and read the best of Twitter Threads about #LIVES2022
Most recents (24)
Last up we have Hot Topics…. #LIVES2022 
First comes @JAMyburgh with #SuDDICU looking at selective decontamination (SDD) of the digestive tract on hospital mortality
(To know- Aim of SDD is to prevent VAP caused by pathogenic gram negatives organisms and overgrown of fungus from upper GI tract)
(To know- Aim of SDD is to prevent VAP caused by pathogenic gram negatives organisms and overgrown of fungus from upper GI tract)
The paper is open access here
jamanetwork.com/journals/jama/…
And summarised in graphic by @JAMA_current.
jamanetwork.com/journals/jama/…
And summarised in graphic by @JAMA_current.
🧠 Heading here this morning for joint @ERC_resus session ‘How do I predict neurological outcome after cardiac arrest” at #LIVES2022
This is a core part of my day to day and frequent conversation I have with the junior team so interested to listen …
This is a core part of my day to day and frequent conversation I have with the junior team so interested to listen …
So far the audience have been asked four times to move closer to the front. Nobody moves.
The first q is ‘how do you do it’.
Sandroni says Neuron specific enolase (NSE) for 3 days, clinical exam from day 3, EEG starting early…used later, CT is repeated in patients with prolonged unconsciousness and MRI in those that aren’t waking up..
They have protocol on unit
Sandroni says Neuron specific enolase (NSE) for 3 days, clinical exam from day 3, EEG starting early…used later, CT is repeated in patients with prolonged unconsciousness and MRI in those that aren’t waking up..
They have protocol on unit
It’s 16:40 - I’ve come to palliative care session
I *think* (but cannot be sure) that it won’t mention biomarkers
Impressive turnout for such late session. It’s actually nearly full!
#LIVES2022
I *think* (but cannot be sure) that it won’t mention biomarkers
Impressive turnout for such late session. It’s actually nearly full!
#LIVES2022
First speaker Hartog said she’s surprised by the turnout ☺️
She comments that the WHO definition of palliative care (PC) doesn’t mention death
She directs us to concept that it accompanies curative care - then takes overtakes it - and eventually, no even continues after death
She comments that the WHO definition of palliative care (PC) doesn’t mention death
She directs us to concept that it accompanies curative care - then takes overtakes it - and eventually, no even continues after death
She points to this paper and graphic.
(You should know now the room is so full that people are standing, which is tiring imagine- but good to see for such an important topic)
link.springer.com/content/pdf/10…
(You should know now the room is so full that people are standing, which is tiring imagine- but good to see for such an important topic)
link.springer.com/content/pdf/10…
Carolyn Calfee Clinical and Biological phenotypes of ARDS
- what do they have in common?
ARDS : subgrouping since the begining
- sepsis vs. non sepsis
- hyper vs. hypoinflamm
- reactive vs uninflamed
#ventilation #ards #phenotypes #LIVES2022
- what do they have in common?
ARDS : subgrouping since the begining
- sepsis vs. non sepsis
- hyper vs. hypoinflamm
- reactive vs uninflamed
#ventilation #ards #phenotypes #LIVES2022
Are clinical phenotypes biologically distinct?
looking at Trauma vs. Non trauma
ICAM-1 , SP-D, vWF, sTNFr-1 are different.
What about in "Direct" vs. "indirect"
or "Diffuse" vs "focal" -- sRAGE comes up again.
pubmed.ncbi.nlm.nih.gov/17944012/
#ventilation #ARDS #LIVES2022
looking at Trauma vs. Non trauma
ICAM-1 , SP-D, vWF, sTNFr-1 are different.
What about in "Direct" vs. "indirect"
or "Diffuse" vs "focal" -- sRAGE comes up again.
pubmed.ncbi.nlm.nih.gov/17944012/
#ventilation #ARDS #LIVES2022
Mariangela PELLEGRINI
Uppsala- Sweden
"Do we Need a biological definition of ARDS"
- Berlin definition has NO Diffuse alveolar damage .
- the Berlin defn does not capture well
Frohlich - different definitions specificity of 0.63, 0.42, 0.31 even!
#ventilation #ards #LIVES2022
Uppsala- Sweden
"Do we Need a biological definition of ARDS"
- Berlin definition has NO Diffuse alveolar damage .
- the Berlin defn does not capture well
Frohlich - different definitions specificity of 0.63, 0.42, 0.31 even!
#ventilation #ards #LIVES2022
academic.oup.com/bja/article/11…
The BJA article by Frohlich.
Fibrosis only starts after 7 days
Thille article : atsjournals.org/doi/full/10.11…
The BJA article by Frohlich.
Fibrosis only starts after 7 days
Thille article : atsjournals.org/doi/full/10.11…
In essence, different disease processes are happening to the lung at different times in the "ARDS"
pubmed.ncbi.nlm.nih.gov/24429204/
pubmed.ncbi.nlm.nih.gov/24429204/
ARDS - new definition or phenotypes by @GicoBellani refreshing with Kigali definition of ARDS - useful not just low resource but during pandemic in supposedly high income settings and only draw back is no PEEp requirement #ards #ventilation #LIVES2022 @ESICM
@GicoBellani @ESICM Resolved versus confirmed ARDS
- prospectively applying Berlin definition did work but if ya wait 24 hrs and re-measure P/F ratio, you end up stratifying much better.
- Better separation of groups
pubmed.ncbi.nlm.nih.gov/29632996/
#ventilation #LIVES2022
- prospectively applying Berlin definition did work but if ya wait 24 hrs and re-measure P/F ratio, you end up stratifying much better.
- Better separation of groups
pubmed.ncbi.nlm.nih.gov/29632996/
#ventilation #LIVES2022
@GicoBellani @ESICM Whichever definition - american european consensus or Berlin or Kigali -- all goes back to Ashbaugh original paper in 1967
thelancet.com/journals/lance…
Why are we so confused when it comes to ARDS definition ?
#ards #ventilation #LIVES2022 @ESICM
thelancet.com/journals/lance…
Why are we so confused when it comes to ARDS definition ?
#ards #ventilation #LIVES2022 @ESICM
Up next at #LIVES2022
🧠 Optimising Brian perfusion after resuscitation.
This is another debate (read chat, more than debate)
So I’ll try to keep up…
🧠 Optimising Brian perfusion after resuscitation.
This is another debate (read chat, more than debate)
So I’ll try to keep up…
It opens by saying we know that 2/3 of unconscious patients in ITU post cardiac arrest die
And most of them die from brain injury
(I’ll use HIE to say hypoxic ischaemic encephalopathy from now)
❓Do we need to improve perfusion to the brain and can it help anyway❓
And most of them die from brain injury
(I’ll use HIE to say hypoxic ischaemic encephalopathy from now)
❓Do we need to improve perfusion to the brain and can it help anyway❓
HIE brains have inflammation, reorganisation and things which alter interaction with systemic circulation.
Robba is surprised that we don’t seem to categorise post arrest brains as other brain injuries and so treat them with the same systematic approach
Robba is surprised that we don’t seem to categorise post arrest brains as other brain injuries and so treat them with the same systematic approach
Next : Mypinder SEKHON on cardiac arrest in COVID-19 era.
Works in Vancouver
COVID 19 era cardiac arrest ARE a lot less sexy with all the PPE. #als #covid19 #resuscitation #LIVES2022
@ESICM
Works in Vancouver
COVID 19 era cardiac arrest ARE a lot less sexy with all the PPE. #als #covid19 #resuscitation #LIVES2022
@ESICM
@ESICM Let's look at epidemiology. Northern Italy, Manhattan - COVID hit hard and has impact on other diseases.
e.g., OHCA in Italy during COVID 19 massive spike.
e.g., OHCA in Italy during COVID 19 massive spike.
NEXT Speaker : VA ecmo for which patients?
Alain COMBES
Severe cardiogenic shock has different phenotypes
1. medical cardiogenic shock(AMI, end stage dilated CM, myocarditis, septic shock)
2. Post cardiotomy refractory CS (post CABG)
#LIVES2022
@ESICM #ecmo #resuscitation #ALS
Alain COMBES
Severe cardiogenic shock has different phenotypes
1. medical cardiogenic shock(AMI, end stage dilated CM, myocarditis, septic shock)
2. Post cardiotomy refractory CS (post CABG)
#LIVES2022
@ESICM #ecmo #resuscitation #ALS
@ESICM 2022 what do the guidelines say
- ESC recommends short term MCS should be considred in cardiogenic shock.
IABP may be considered but not routinely recommended in post MI
#LIVES2022
- ESC recommends short term MCS should be considred in cardiogenic shock.
IABP may be considered but not routinely recommended in post MI
#LIVES2022
what about in refractory cardiac arrest?
ERC - ESICM guidelines 2021
- timing of CAG if no evidence ofr ST segment evaluation.
which means we will end up treating a lot of patients with stent and anticoagulation
ERC - ESICM guidelines 2021
- timing of CAG if no evidence ofr ST segment evaluation.
which means we will end up treating a lot of patients with stent and anticoagulation
TOMAHAWK trial : delayed or early invasive angiography -- no effec.
#LIVES2022
- immediate catheterisation for non ST elevationrr
#LIVES2022
- immediate catheterisation for non ST elevationrr
Updates on Advanced life supprot by Theresa OLASVEENGEN
Vasopressors and Drugs : recent trial outcomes.
#LIVES2022
@ESICM #als #resuscitation
Vasopressors and Drugs : recent trial outcomes.
#LIVES2022
@ESICM #als #resuscitation
@ESICM 2020 ILCOR consensus : strong recommendation to use "ADRENALINE" in cardiac arrest, if you dont have it "LIDOCAINE".
Adrenaline to placebo comparison is mainly 1 older trial with latest PARAMEDIC 2
pubmed.ncbi.nlm.nih.gov/30980877/
Adrenaline to placebo comparison is mainly 1 older trial with latest PARAMEDIC 2
pubmed.ncbi.nlm.nih.gov/30980877/
@ESICM PARAMEDIC 2 - big study
8007 pts, adrenaline 4000, placebo 3999
- a lot of discussion post trial
- need a nuanced interpretation.
- 19 "more good" survivors and 5 "more bad" survivors in adrenaline arm.
nejm.org/doi/full/10.10…
8007 pts, adrenaline 4000, placebo 3999
- a lot of discussion post trial
- need a nuanced interpretation.
- 19 "more good" survivors and 5 "more bad" survivors in adrenaline arm.
nejm.org/doi/full/10.10…
🫁 🧬 ARDS in Sepsis - Are biomarkers helpful? #LIVES2022
(The answer for me is - minimally…I rarely have access to them at the beside 🛌 but I presume the answer from JM Constantin has meat to it, so I’m here to listen)
(The answer for me is - minimally…I rarely have access to them at the beside 🛌 but I presume the answer from JM Constantin has meat to it, so I’m here to listen)
We start here by asking is ARDS due to sepsis the same as that due to peritonitis or pneumonia?
And he has now changed the title to Are biomarkers helpful in ARDS?
And he has now changed the title to Are biomarkers helpful in ARDS?
Q1 Do we need them for diagnosis?
No- The Berlin criteria does not need them
No- The Berlin criteria does not need them
Jokes, it isn’t
“Are biomarkers helpful in characterising inflammation V infection?”
“Are biomarkers helpful in characterising inflammation V infection?”
The goal is to prevent both under AND over treatment of infection.
As clinicians we have bias
- Tend towards ‘action’
- Over estimate risk of infection
- Over estimate/misattribute improvement (outcome bias)
As clinicians we have bias
- Tend towards ‘action’
- Over estimate risk of infection
- Over estimate/misattribute improvement (outcome bias)
NEXT : @AriErcole
Association is not necessarily a causation
RCTs are thought of as "gold standard" for a good reason.
"Randomisation" eliminates influences of confounders.
- allows "causality" inference.
Association is not necessarily a causation
RCTs are thought of as "gold standard" for a good reason.
"Randomisation" eliminates influences of confounders.
- allows "causality" inference.
@AriErcole RCTs require relatively little prior knowledge.
But
"DO WE HAVE ASSURANCE OF THIS" ?
we try to "by having a inclusion criteria"
🧐 we can only control what we know
RCTs have limitations - dont really imply causality absolutely.
@ESICM #datascience #ai #ml #icudata #RCT
But
"DO WE HAVE ASSURANCE OF THIS" ?
we try to "by having a inclusion criteria"
🧐 we can only control what we know
RCTs have limitations - dont really imply causality absolutely.
@ESICM #datascience #ai #ml #icudata #RCT
One of the useful things about a conference in Europe is the opportunity to understand a breath of socio-cultural perspectives (it’s almost like we’re better together 💁🏻♀️🇪🇺)
Anyway, looking forward to this - let’s go
#LIVES2022
Anyway, looking forward to this - let’s go
#LIVES2022
This is a joint session from ethics and metabolism & nutrition section. They start with Arabi who highlights the variability - he’s trained in US, works in Saudia Arabia and has relationship with Australia
He starts by pointing to this paper
pubmed.ncbi.nlm.nih.gov/25581712/
He starts by pointing to this paper
pubmed.ncbi.nlm.nih.gov/25581712/
He highlights that there is more agreement for withholding than withdrawing nutrition and that attitude are surprisingly consistent across this large part of the world
He then says that artificial nutrition in Saudia Arabia is more likely to be considered a basic part of care
He then says that artificial nutrition in Saudia Arabia is more likely to be considered a basic part of care
NEXT Adaptive and Platform trial designs by @Lennie333 #datascience #ai #ml #icudata
#LIVES2022 #ventilation
@ESICM
we assume "large effect sizes" in ICU trials
#LIVES2022 #ventilation
@ESICM
we assume "large effect sizes" in ICU trials
@Lennie333 @ESICM this is because otherwise we will need large "n" and long time for trials.
e.g., anti-hypertensives - you dont want to test one drug at one dose. you want to test a range of doses and a range of duration.
third-thing : we struggle to find a end-point especially in critical care
e.g., anti-hypertensives - you dont want to test one drug at one dose. you want to test a range of doses and a range of duration.
third-thing : we struggle to find a end-point especially in critical care
@Lennie333 @ESICM huge effort doing RCT but we use "mortality" yes/no as a very binary endpoint. For patient, length of stay, quality of life after d/c important end points beyond survival.
in RCT, we cant learn whilst the trials are still running. in classic RCT.
in RCT, we cant learn whilst the trials are still running. in classic RCT.
NEXT:Interfacing ICU data Nicolas Bennet
- Nicolas was very pleased to hear Chris Sauer(earlier speaker) advocating use of 2 -data set at least
@ESICM #criticalcare #ai #ml #icudatasets
- Nicolas was very pleased to hear Chris Sauer(earlier speaker) advocating use of 2 -data set at least
@ESICM #criticalcare #ai #ml #icudatasets
@ESICM eth-mds.github.io/ricu/
showcasing this R dataset
starting with
'r'
> library(ricu)
> lact (loaded all lactate data)
'r'
showcasing this R dataset
starting with
'r'
> library(ricu)
> lact (loaded all lactate data)
'r'
@ESICM NEVER THOUGHT THAT I would be tweeting code in an ICU conference :)) @ESICM #datascience :P #datascience #LIVES2022
NEXT Inventory and Comparison of ICU datasets by Christopher SAUER
"Why talk on differences in ICU databases?"
Ans: becuase data is "CORE"
@ESICM #ml #ai #databases #datascience #LIVES2022
"Why talk on differences in ICU databases?"
Ans: becuase data is "CORE"
@ESICM #ml #ai #databases #datascience #LIVES2022
@ESICM Merit of publicly available ICU databases
- no randomzined evidence exists for most clinical situations
-data and pt level insights incredibly useful.
-local epidemiology and treatment difers
-real world data sets help deliver optimal treatment policies.
#DataScience #LIVES2022
- no randomzined evidence exists for most clinical situations
-data and pt level insights incredibly useful.
-local epidemiology and treatment difers
-real world data sets help deliver optimal treatment policies.
#DataScience #LIVES2022
@ESICM 1st publicly available dataset MIMIC-3 in 2016,
Beth Israel Deaconess Medical Centre, Boston,MA
>70,000 icu stays, 2008 to 2019
now also includes chest x-rays, emergency room data
- large, community developed Github repo.
#DataScience
Beth Israel Deaconess Medical Centre, Boston,MA
>70,000 icu stays, 2008 to 2019
now also includes chest x-rays, emergency room data
- large, community developed Github repo.
#DataScience
Day 2. Starting on pitfalls in leveraging EHR by Stephanie HYLAND @ESICM #criticalcare #ehr #datascience #ai #LIVES2022
This problem is mainly for ML engineers who may not have talked to domain expert or clinicians / end users.
Pitfall 1 : sampling bias
"whos included in the analysis"
"who in your EHR"?
- e.g., - COVID prediction dataset where missing all blood tests were removed, but this missingess has a meaning. Thus not generalisable.
e.g., yesterday I mentioned about females < 6% of sample popn
"whos included in the analysis"
"who in your EHR"?
- e.g., - COVID prediction dataset where missing all blood tests were removed, but this missingess has a meaning. Thus not generalisable.
e.g., yesterday I mentioned about females < 6% of sample popn
Extra-corporeal therapies in Resp Failure
@CarolynCalfee
- Phenotypes in ARDS
Many phenotypes in ARDS: severity of ARDS, aetiology,
- physiologic
- does any of this response to differently to ECMO?
#LIVES2022
#ventilation
#extracorpreal @ESICM
@CarolynCalfee
- Phenotypes in ARDS
Many phenotypes in ARDS: severity of ARDS, aetiology,
- physiologic
- does any of this response to differently to ECMO?
#LIVES2022
#ventilation
#extracorpreal @ESICM
@CarolynCalfee @ESICM Severe ARDS phenotypes EOLIA using P/F ratio
- within 1st 7 days
- within this, which pt benefits most.
Meta-analysis on ECMO patients
- multiple subgroups but none of them statistically significant
- only key difference is No of organ failure . >2 ecmo less likely to work
- within 1st 7 days
- within this, which pt benefits most.
Meta-analysis on ECMO patients
- multiple subgroups but none of them statistically significant
- only key difference is No of organ failure . >2 ecmo less likely to work
Next I’m here for this @ESICM #LIVES2022 chat on ‘diversity’ with amongst others @iceman_ex
My first thought is that this should be in a main theatre
My first thought is that this should be in a main theatre
The first question is ‘what is’ diversity
@ElieAzoulay5 says it is ‘us…all of us”
(My own thought on that is the sense of ‘us’ is sometimes the issue but I get the intention)
Ellie says there’s a generation gap - need to understand elements of language that we don’t share
@ElieAzoulay5 says it is ‘us…all of us”
(My own thought on that is the sense of ‘us’ is sometimes the issue but I get the intention)
Ellie says there’s a generation gap - need to understand elements of language that we don’t share
(I agree with that we can’t be afraid to learn form each other)
🫁 Over the past years we have started using NIV more and more for respiratory fairly …practice changed under pressure
But now we’ve taken a breath
When do we use NIV and more importantly …when do we move on?
Follow along for debate #LIVES2022
But now we’ve taken a breath
When do we use NIV and more importantly …when do we move on?
Follow along for debate #LIVES2022
Bellani says that any T1RF normally warrants a trial of helmet free flowing CPAP to see if they improve by monitoring with RR and paO2
Jaber says no, just get the FiO2 to >92% and then get them to ICU and see what you need…NIV..HiFlo etc
Jaber says no, just get the FiO2 to >92% and then get them to ICU and see what you need…NIV..HiFlo etc
So now what if the patient is on 30L/min and SaO2 not achieving outcomes….
Roca says to asks if the situation is flow dependent (eg work of breathing) then he would first try actual HiFlo (60L/min)
And they ask should we ask patient?
Roca says yes, even considering loss of
Roca says to asks if the situation is flow dependent (eg work of breathing) then he would first try actual HiFlo (60L/min)
And they ask should we ask patient?
Roca says yes, even considering loss of
Amsterdam UMC on Implementation: @drPaulElbers Conference conflicts of interest : chair of data science edition.
"Working AI to Implementation"
#criticalcare #DataScience #ai #aitobedside #LIVES2022
@ESICM
"Working AI to Implementation"
#criticalcare #DataScience #ai #aitobedside #LIVES2022
@ESICM
@drPaulElbers @ESICM PacMed Model to help discharge patients from ICU. Autokinetics for antibiotic dosing.
These 2 are currently implemented. @patrickthoral also involved in discharge models.
These 2 are currently implemented. @patrickthoral also involved in discharge models.
@drPaulElbers @ESICM @patrickthoral - ICU natural habitat
- large vol of data
- frequent decision making
BUT there is a problem in ICU and data.
- high variability
pubmed.ncbi.nlm.nih.gov/36173632/
- large vol of data
- frequent decision making
BUT there is a problem in ICU and data.
- high variability
pubmed.ncbi.nlm.nih.gov/36173632/
NEXT: Who's "high risk" in ICU? Nicolas Bennett - Zurich, Switzerland.
reminds me of NELA score development in UK.
Declaration : he now works for industry (known side effect for medics doing data science )
@ESICM #criticalcare #ai #datascience #LIVES2022
reminds me of NELA score development in UK.
Declaration : he now works for industry (known side effect for medics doing data science )
@ESICM #criticalcare #ai #datascience #LIVES2022
@ESICM Interesting : eventually end up writing R package. cran.r-project.org/web/packages/r…
#sepsis classification using MIMIC-3 - time series data. Time-series classficiation.
#sepsis classification using MIMIC-3 - time series data. Time-series classficiation.
