https://www.facebook.com/groups/141465626573458/214568779263142/
Hear Dr Ram Rajagopalan speak about the adequacy of the Surviving Sepsis Guidelines

Good Afternoon.
    Burns management has always been a difficult zone for intensivists. Resuscitation and maintenance of hemodynamic stability seems to be a tight rope walk. There is no definite conclusion on "how much fluid is too much fluid" in Burns management. The concept of GIPS is particularly valid during management of severe Burns.
   This week we review a study on using a novel technique for optimum management of fluid therapy during Burns management.

An objective measure for the assessment and management of fluid shifts in acute major burns 
Kenworthy et al. Burns & Trauma (2018) 6:3 

Kenworthy et al evaluated the role of Bio Impedance Spectroscopy in identifying the volume status of patients presenting within 48 hrs of sustaining burn injuries greater than 15%. The investigators also attempted to factor in the dressings which are employed to cover the burn area. This was an observational study carried out over two years. it is  a small cohort of 21 patients. The resuscitation fluid of choice was Ringer Lactate and the target was to maintain a urine output 0.5–1.0 ml/kg/h for the first 36–48 h after burn injury.
Quantum of fluid was decided by the Parkland formula. Resistance patterns showed a significant decrease with increasing fluid. Fluid therapy was reflected in a minute to minute increase in Intra-cellular and Total Body Fluids. The percentage of burns also correlated well with the change in the resistance patterns. The investigators found that when a patient’s initial TBF increased by 1 L, R0 (Resistance at 0 frequency) decreased by 5.78 Ω (p < 0.01), R i ( intra cellular frequency) decreased 28.79 Ω (p  < 0.01) and R inf (Resistance at infinite frequency) decreased 5.31 Ω (p < 0.01). A calculator was developed to identify the change in parameters due to the dressing applied.
        This study seems to have identified a reliable marker of fluid characteristics and overload in Burns situation. The novelty of this study seems to be the ability to correlate the impedance characteristics real time in a minute to minute capture. The effect of the burns dressing was significant and needed to be interpreted with correction.

My comments:
1. BIS seems to be able to provide some answers to the eternal question of when to stop fluid resuscitation
2. It has given a direction for a targeted resuscitation of Burns without causing harm
3. Centres which deal with Burns on regular basis could try this method out to provide some guidance to the others.

Some new articles.

1. Levy B et al Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction Journal of the American College of Cardiology Volume 72, Issue 2, 10 July 2018, Pages 173-182

- main conclusion seems to be against the use of adrenaline in view of higher incidence of refractory cardiogenic shock

2. Rochwerg. Corticosteroids in Sepsis: An Updated Systematic Review and Meta-Analysis. Crit Care Med 2018;epublished July 2nd

3.  Kanjanahattakij. New-onset atrial fibrillation is associated with increased mortality in critically ill patients: a systematic review and meta-analysis. Acta Cardiol 2018;5:1-8

4. Management of Acute Respiratory Distress Syndrome. Faculty of Intensive Care Medicine 2018;epublished July 6th

5. Liu. Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care Med 2018;epublished July 3rd 

Good reviews this week

1. Kotfis. ICU delirium ― a diagnostic and therapeutic challenge in the intensive care unit. Anaesthesiol Intensive Ther 2018;50(2):160-167
2. Van der Mullen. Assessment of hypovolaemia in the critically ill. Anaesthesiol Intensive Ther 2018;50(2):141-149
3. Bauer. Deterioration of Organ Function As a Hallmark in Sepsis: The Cellular Perspective. Front Immunol 2018;9:1460
4. Gupta. ECMO in Poisoning. J Card Crit Care 2017;1(02):82-88

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Good Morning

   This week we discuss an article discussing the role of microcirculatory dysfunction in traumatic hemorrhage 

Although microcirculation is a focal point in most discussions on sepsis, its role in other forms of shock is discussed less often.

Microcirculatory Impairment Is Associated With Multiple Organ Dysfunction Following Traumatic Hemorrhagic Shock: The MICROSHOCK Study

Hutchings et al CCM JUNE 27 2018.

                   This study carried out in three major trauma centres in the UK attempted to study the pattern of microcirculatory dysfunction in traumatic hemorrhage and tried to identify a threshold for the prediction of MODS. The time points of interest were Day 0 ( within 12 hrs of hemostasis) D0 + 24 hrs and D0 + 48 hrs. Hyperlactatemia and invasive ventilatory support were part of the inclusion criteria. Incident Dark Field Videomicroscopy was used for assessment of the sublingual microcirculation. Cardiac output was measured using oesophageal doppler. 

                  The main findings seem to suggest that microcirculatory parameters like Total Vessel Density, Perfused Vessel Density and Microcirculatory flow index showed better ROC values for predicting worsening SOFA scores than Cardiac index. Systolic Blood pressure showed the least ROC characteristics. Perfused Vessel Density showed the best discriminatory ability. This discriminatory ability persisted throughout all time points of interest.

What I learnt from the study?

1. Shock is a unique pathophysiological state irrespective of etiology

2. Microcirculatory derangements probably occur before microcirculatory changes

3. Targeting systolic blood pressure alone may delay attention to tissue hypoperfusion

4. Assessment of microcirculation may become standard of care in future