251 CMEinfo presents a definitive multimedia course THE BRIGHAM BOARD REVIEW IN CRITICAL CARE MEDICINE from The Brigham Board Review in Critical Care Medicine Presented by: Brigham and Women’s Hospital Provided by: Oakstone Publishing, LLC DATE OF ORIGINAL RELEASE: May 31, 2017 DATE CREDITS EXPIRE: May 31, 2020 TARGET AUDIENCE: The primary group of learners will be fellows/trainees and practicing critical care specialists (MDs), NP’s, and other professional affiliates (internists with an interest in critical care) who are preparing to take ABIM Board Review or Recertification Examinations or who seek CME activities to improve patient care in the area of critical care medicine Currently, the target audience is regional, national & international ESTIMATED TIME TO COMPLETE: It is estimated that it should take the average learner 30.5 hours to complete the activity ACCREDITATION: Oakstone Publishing, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians Oakstone Publishing, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation DESIGNATION: Oakstone Publishing, LLC designates this enduring material for a maximum of 30.5 AMA PRA Category Credits™ Physicians should claim only the credit commensurate with the extent of their participation in the activity Contact hours: 30.5 Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 30.5 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit SPECIAL PREREQUISITES FOR PARTICIPANTS: There are no prerequisites for participants METHOD OF PARTICIPATION: Review Video/Audio program, complete the comprehensive activity evaluation and score 70% or greater on the required posttest to assess the knowledge gained from reviewing the program 251 LEARNING OBJECTIVES: At the conclusion of this activity, the participant will be able to: • • • • • • Apply current/recommended critical care guidelines in clinical practice; Perform differential diagnosis of complex clinical presentations related to critical care disorders; Identify and Apply current therapeutic options for specific critical care disorders; Analyze and Interpret up-to-date literature relevant to clinical practice in critical care medicine; Recognize and Apply knowledge of pathophysiology as it applies to management of critical care disorders; Apply knowledge gained to the ABIM certification/recertification critical care examinations FACULTY AFFILIATIONS DISCLOSURE: Oakstone Publishing, LLC has assessed conflict of interest with its faculty, authors, editors, and any individuals who were in a position to control the content of this CME activity Any identified relevant conflicts of interest were resolved for fair balance and scientific objectivity of studies utilized in this activity Oakstone Publishing’s planners, content reviewers, and editorial staff disclose no relevant commercial interests Disclosure information for individuals in control of the content of the activity can be found at the beginning of each lecture WARNING: The copyright proprietor has licensed the picture contained on this recording for private home use only and prohibits any other use, copying, reproduction, or performance in public, in whole or in part (Title 17 USC Section 501 506) CMEinfo is not responsible in any way for the accuracy, medical or legal content of this recording You should be aware that substantive developments in the medical field covered by this recording may have occurred since the date of original release © 2017 Ebix, Inc DBA Oakstone Publishing LLC CMEinfo is a registered trademark of Oakstone Publishing, LLC 251 The Brigham Board Review in Critical Care Medicine Faculty List Course Director Gerald L Weinhouse, MD Assistant Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Faculty Rebecca M Baron, MD Assistant Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Phillip C Camp, Jr., MD Instructor in Surgery Harvard Medical School Division of Thoracic Surgery Department of Surgery Brigham and Women’s Hospital Bartolome R Celli, MD Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Kenneth B Christopher, MD Assistant Professor of Medicine Harvard Medical School Renal Division Department of Medicine Brigham and Women’s Hospital Jean M Connors, MD Assistant Professor of Medicine Harvard Medical School Division of Hematology Department of Medicine Brigham and Women’s Hospital Akshay Desai, MD, MPH Associate Professor of Medicine Harvard Medical School Division of Cardiovascular Medicine Department of Medicine Brigham and Women’s Hospital Katherine E Economy, MD Assistant Professor of Obstetrics, Gynecology and Reproductive Biology Harvard Medical School Department of Obstetrics and Gynecology Brigham and Women’s Hospital James F Gilmore, PharmD Clinical Pharmacy Specialist Department of Pharmacy Services Brigham and Women’s Hospital Hilary Goldberg, MD Assistant Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Edward Kelly, MD Assistant Professor of Surgery Harvard Medical School Division of Trauma, Burn, and Surgical Critical Care Department of Surgery Brigham and Women’s Hospital Samuel Goldhaber, MD Professor of Medicine Harvard Medical School Division of Cardiovascular Medicine Department of Medicine Brigham and Women’s Hospital Michael Klompas, MD Associate Professor of Population Medicine Harvard Medical School Division of Infectious Diseases Department of Medicine Brigham and Women’s Hospital Kathleen Haley, MD Assistant Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Daniela Lamas, MD Instructor in Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Galen Henderson, MD Assistant Professor of Neurology Harvard Medical School Department of Neurology Brigham and Women’s Hospital Linda Lee, MD Assistant Professor of Medicine Harvard Medical School Division of Gastroenterology, Hepatology and Endoscopy Department of Medicine Brigham and Women’s Hospital Margo Hudson, MD Assistant Professor of Medicine Harvard Medical School Division of Endocrinology, Diabetes and Hypertension Department of Medicine Brigham and Women’s Hospital Jennifer Johnson, MD Instructor in Medicine Harvard Medical School Division of Infectious Diseases Department of Medicine Brigham and Women’s Hospital Anthony F Massaro, MD Instructor in Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Melanie Maytin, MD Instructor in Medicine Harvard Medical School Division of Cardiovascular Medicine Department of Medicine Brigham and Women’s Hospital Julia McNabb-Baltar, MD, MPH Instructor in Medicine Harvard Medical School Division of Gastroenterology, Hepatology and Endoscopy Department of Medicine Brigham and Women’s Hospital Paul F Nuccio, MS, RRT, FAARC Director of Pulmonary Services Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Dana-Farber Cancer Institute James Rawn, MD Instructor in Surgery Harvard Medical School Division of Cardiac Surgery Department of Surgery Brigham and Women’s Hospital Chanu Rhee, MD Instructor in Population Medicine Harvard Medical School Division of Infectious Diseases Department of Medicine Brigham and Women’s Hospital Malcolm K Robinson, MD Assistant Professor of Surgery Harvard Medical School Division of General Surgery Department of Surgery Brigham and Women’s Hospital Anna Rutherford MD, MPH Assistant Professor of Medicine Harvard Medical School Division of Gastroenterology, Hepatology and Endoscopy Department of Medicine Brigham and Women’s Hospital Raghu R Seethala, MD Instructor in Emergency Medicine Harvard Medical School Department of Emergency Medicine Brigham and Women’s Hospital Benjamin M Scirica, MD, MPH, FACC Associate Professor of Medicine Harvard Medical School Division of Cardiovascular Medicine Department of Medicine Brigham and Women’s Hospital Simon Talbot, MD Assistant Professor of Surgery Harvard Medical School Division of Plastic Surgery Department of Surgery Brigham and Women’s Hospital Taylor Thompson, MD Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Massachusetts General Hospital J Kevin Tucker, MD Assistant Professor of Medicine Harvard Medical School Renal Division Department of Medicine Brigham and Women’s Hospital Aaron Waxman, MD, PhD Associate Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Presented by: Brigham and Women’s Hospital Provided by: Oakstone Publishing, LLC The Brigham Board Review in Critical Care Medicine May 31, 2017 Topic/Speaker Book Page # SHOCK Septic Shock - Princples and Practices of Resuscitation Rebecca M Baron, MD Sepsis: New Definitions and Guidlines Chanu Rhee, MD Hemodynamic Monitoring Aaron Waxman, MD, PhD Hemorrhagic Shock Edward Kelly, MD Approach to Diagnosis and Management of Cardiogenic Shock Akshay Desai, MD, MPH 25 62 86 106 RESPIRATORY FAILURE ARDS-New Definition and Treatment Taylor Thompson, MD ARDS – Mechanical Ventilation Taylor Thompson, MD Management of Severe Obstructive Lung Disease Bartolome R Celli, MD Invasive and non-Invasive Mechanical Ventilation: Basic Principles and Goals Paul F Nuccio, MS, RRT, FAARC Mechanical Ventilation:Liberation and ABCDEF Bundle Anthony F Massaro, MD 143 169 196 237 258 CARDIAC ISSUES IN THE ICU Acute Coronary Syndromes Benjamin M Scirica, MD, MPH, FACC Arrhythmias Melanie Maytin, MD Indications and management of implantable electronic cardiac devices in ICU patients Melanie Maytin, MD Post-Cardiac Arrest Care Benjamin M Scirica, MD, MPH, FACC Pulmonary Embolism in the ICU Samuel Goldhaber, MD 286 312 343 403 429 GI ISSUES IN THE ICU Pancreatitis Julia McNabb-Baltar, MD 445 Presented by: Brigham and Women’s Hospital Provided by: Oakstone Publishing, LLC The Brigham Board Review in Critical Care Medicine May 31, 2017 Topic/Speaker Book Page # GI ISSUES IN THE ICU GI Bleed Linda Lee, MD Acute Liver Failure Anna Rutherford, MD, MPH 463 494 NEURO ISSUES IN THE ICU Advances in Stroke Galen V Henderson, MD Intracranial Hypertension Galen V Henderson, MD Seizures and Status Epilepticus Galen V Henderson, MD Approach to the Comatose Patient Galen V Henderson, MD 521 576 619 647 HEMATOLOGIC ISSUES IN THE ICU Transfusion Practices in the ICU James Rawn, MD Coagulopathies and Thrombocytopenia Jean M Connors, MD 685 726 RENAL ISSUES IN THE ICU Acute Kidney Injury and Renal Replacement Therapy Kenneth B Christopher, MD Acid-base Disorders; ABG’s Kenneth B Christopher, MD 748 777 INFECTIOUS DISEASE ISSUES IN THE ICU Ventilator-Associated Pneumonia: Diagnosis, Therapy, Prevention Michael Klompas, MD Infection, FUO, and Antibiotic Use in the ICU Jennifer A Johnson, MD 802 845 ENDOCRINE ISSUES IN THE ICU Hyperglycemia and Glycemic Control in the ICU Margo Hudson, MD Endocrine Crises in the ICU Margo S Hudson, MD 868 905 Presented by: Brigham and Women’s Hospital Provided by: Oakstone Publishing, LLC The Brigham Board Review in Critical Care Medicine May 31, 2017 Topic/Speaker Book Page # GENERAL CARE ISSUES IN THE ICU Fundamentals of Clinical Nutrition: Essentials for the Critical Care Specialist Malcolm K Robinson, MD Prophylaxis in the ICU Kathleen Haley, MD 939 976 SURGICAL CRITICAL CARE ISSUES IN THE ICU Treatment of the Patient with Burns and Inhalational Injuries Simon G Talbot, MD Abdominal Catastrophes and Abdominal Compartment Syndrome Edward Kelly, MD Obstetrical Critical Care Katherine E Economy, MD 998 1030 1051 MISCELLANEOUS ICU ISSUES Ethical Dilemmas in the ICU Kathleen Haley, MD Critical Care Pharmacology James F Gilmore , PharmD Toxic Ingestions J Kevin Tucker, MD Sedation and Delirium in the ICU Gerald L Weinhouse, MD ICU Issues for the Transplant Patient Hilary Goldberg, MD Mechanical Support Devices in ICU Phillip C Camp, Jr., MD Ultrasound in the ICU: What Every Intensivist Should Know Raghu R Seethala, MD Post Intensive Care Syndrome Daniela Lamas, MD 1098 1118 1147 1187 1208 1234 1273 1315 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved “Septic Shock: Principles and Practices of Resuscitation” Rebecca M Baron, M.D Pulmonary/Critical Care Medicine Associate Physician, Brigham and Women’s Hospital Assistant Professor of Medicine, Harvard Medical School 2017 Disclosures: None Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Treatment? • No studies about interventions for PICS per se • Emphasis should be on recognition and education • However, several studies on prevention Prevention is key! • Decrease ICU length of stay • Decrease duration of mechanical ventilation • Decrease delirium Best practices in the ICU have the potential to reduce PICS 1332 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved • Would interruption of sedation cause psychological distress? • In fact, evidence for reduction in PTSD AJRCCM 2003 What about late cognitive/physical rehab • Pilot, feasibility RCT (8 control, 13 intervention) • ICU survivors with cognitive or physical impairment at discharge (BRAIN-ICU) • Intervention: in-home cognitive, physical, function rehab via telemedicine x months • in-person visits • televisits • Outcomes at month Jackson J, Ely EW et al Cognitive and Physical Rehabilitation of ICU Survivors: results of the RETURN randomized controlled pilot investigation Crit Care Med Apr2012; 40 (4): 1088-1097 1333 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Jackson CCM 2012 ICU Diaries and PTSD “I started to see this pattern of people with flashbacks and nightmares They had very little factual memory, but also had these hallucinations, paranoid delusions of nightmares and alien abductions and nurses trying to kill them That seemed to be the precipitant for PTSD for a portion of the patients — they couldn’t reject these memories.” - Christina Jones, nurse consultant in UK 1334 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved ICU Diaries Crit Care 2010 1335 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved ICU Diaries • Patients requiring more than 72 hours in ICU • PTSD assessed at and months • Diary given out to patients at month (after PTSD assessment) ICU Diaries: Should everyone it? Icu-diary.org 1336 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved PICS – F: What to do? • Things we try: • Communication via frequent family meetings, open visitation, family members on rounds (observational data) • Family participation in bedside care of patients (e.g applying lip balm, massage) • No clear data • Proactive palliative care meetings with families of patients on vent > days, not expected to wean or die in 72 hours did not reduce anxiety/depression Outline • Epidemiology • Post-intensive care syndrome (PICS) • PICS – Family • Treatment? Prevention Research and Clinical Efforts 1337 Copyright â Oakstone Publishing, LLC, 2017 All Rights Reserved Brigham and Women’s ICU Recovery Clinic • Screen for mood disorders, PTSD, cognitive dysfunction and insomnia • Medical follow-up • Medication Reconciliation • Communication with PCP Are they helpful? 1338 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Study plan • 286 post-ICU patients randomly assigned to nurse-led clinic or standard of care • Intervention: visits at 3, months with psych screening and physical rehabilitation • Outcome: HRQOL (SF-36 questionnaire) at year • Anxiety, depression • Healthcare costs • Mortality Cuthbertson BH et al A pragmatic randomised, controlled trial of intensive care follow up programmes in improving longer-term outcomes from critical illness The PRACTICAL study BMC Health Serv Res 2007 Jul 23; 7: 116 Disappointing Results 1339 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Questions about ICU Recovery Clinics • Are they useful? • When to intervene? How often? • Who is likely to get better? Post ICU Clinics – Our Experience • At this time, limited referral • Many want to learn more about what is “normal” post ICU • Psychiatry and neuropsych referral • Relief that someone acknowledges their issues 1340 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved • SCCM THRIVE Initiative • ICU Survivor Support Groups at sites around the country and growing 1341 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved 1342 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Outline • Epidemiology • Post-intensive care syndrome (PICS) • PICS – Family • Treatment? Prevention • Research and Clinical Efforts Review Question #1 A patient comes to your clinic She was recently discharged home after an ICU stay where she was intubated due to respiratory failure from COPD Which psychiatric problems is she most likely to face as a result of post-intensive care syndrome? a Depression, anxiety, post-traumatic stress b Psychosis, anxiety, post-traumatic stress c Post-traumatic stress, hallucinations, suicidality d There are no psychiatric problems that have been associated with intensive care unit admission 1343 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Review Question Answer A patient comes to your clinic She was recently discharged home after an ICU stay where she was intubated due to respiratory failure from COPD Which psychiatric problems is she most likely to face as a result of post-intensive care syndrome? a Depression, anxiety, post-traumatic stress b Psychosis, anxiety, post-traumatic stress c Post-traumatic stress, hallucinations, suicidality d There are no psychiatric problems that have been associated with intensive care unit admission A systematic review of fourteen studies found the median point-prevalence of “clinically significant” depressive symptoms in ICU survivors to be 28% A review of the literature for PTSD in ICU survivors examined fifteen studies and found the median point-prevalence of “clinically significant” PTSD symptoms to be 22% In survivors from the BRAIN-ICU cohort specifically, 37 percent of patients experienced symptoms of depression, which largely seemed to be associated with somatic symptoms Review Question #2 What is the burden of cognitive dysfunction in PICS? a there is no cognitive dysfunction associated with PICS b Around 1/3 of patients a year after critical illness might have cognitive scores similar to those with moderate traumati brain injury c 75% of ICU survivors have cognitive dysfunction d 10% of ICU survivors have cognitive dysfuncion 1344 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved Review Question Answer What is the burden of cognitive dysfunction in PICS? a there is no cognitive dysfunction associated with PICS b Around 1/3 of patients a year after critical illness might have cognitive scores similar to those with moderate traumati brain injury c 75% of ICU survivors have cognitive dysfunction d 10% of ICU survivors have cognitive dysfuncion The BRAIN-ICU study demonstrated the above findings 24% had cognitive scores similar to those with mild Alzheimer’s disease Take Home Messages • We are saving lives • Things we in the ICU have long term consequences • Treatment? Practice good ICU medicine to have good ICU outcomes Educate patients/families about PICS Think of creative ways to impact these problems 1345 Copyright © Oakstone Publishing, LLC, 2017 All Rights Reserved References • Needham DM, Davidson J, Cohen H et al Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference Crit Care Med 2012 Feb;40(2):502-9 • Pandharipande PP, Girard TD, Jackson JC, et al, BRAIN-ICU Study Investigators Long-term cognitive impairment after critical illness N Engl J Med 2013;369(14):1306 • Herridge MS, Tansey CM, Matté A et al Functional disability years after acute respiratory distress syndrome N Engl J Med 2011;364(14):1293 • Herridge MS, Cheung AM, Tansey CM et al One-year outcomes in survivors of the acute respiratory distress syndrome N Engl J Med 2003;348(8):683 • Brummel NE, Girard TD, Ely EW et al Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial Intensive Care Med 2014 Mar;40(3):370-9 Epub 2013 Nov 21 Acknowledgements Brigham and Women’s Hospital • Gerald Weinhouse, MD • Melissa Bui, MD • Stacey Salomon LICSW dlamas@partners.org Vanderbilt • Carla Sevin, MD UCSD • Robert Owens, MD (research support and slides) SCCM THRIVE Initiative 1346 ... Publishing, LLC The Brigham Board Review in Critical Care Medicine May 31, 2 017 Topic/Speaker Book Page # GENERAL CARE ISSUES IN THE ICU Fundamentals of Clinical Nutrition: Essentials for the Critical. .. Oakstone Publishing, LLC The Brigham Board Review in Critical Care Medicine May 31, 2 017 Topic/Speaker Book Page # GI ISSUES IN THE ICU GI Bleed Linda Lee, MD Acute Liver Failure Anna Rutherford, MD,... and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Daniela Lamas, MD Instructor in Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine