annual report2004-2005

scottish intensive care society

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editorial

This year should have produced the Scottish Intensive Care Societies 10th Annual

Newsletter. The ever increasing scale and scope of the Societies activities has meant,

however, that in recent years the Newsletter has increased so much in size and content

that it belies its own title. We have decided therefore to resist the temptation to produce

a landmark 10th Newsletter and instead replace it with a new publication entitled the

Annual Report. This better reflects the character of the publication. It aims to be an

account of the Societies various activities over the year. It should provide a more

accurate record the scope and ambitions of the Society and may even prevent people

throwing it into the bin. I should be grateful to receive any feedback on the change in the

status of the publication and delighted to pass any comments on to the new editor. After

three years I have spiked my last article and am about to hand over editorial control to

Rory Mackenzie.

Philip Oates

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president’s report

Becoming the 7th President of the SICS at theAGM last January was a great honour of whichI am very appreciative. The Society is inextremely good health and our membership isgrowing year on year. The Society grows notonly in size but in the breadth of the front onwhich it operates. Having started as a clubback in 1992 it has slowly grown into anorganisation. This has been an organicprocess with new buds and sprouts, it seems,appearing at regular intervals. I see noreason why we should not continue theprogress made under the canny guidance ofyour last President, Dr Alf Shearer, whodirected the considerable energies of yourCouncil. The expansion we are experiencingwill, I believe, increasingly lead to the Societybeing identified as the legitimate voice ofScottish intensive care. Inevitably this willresult in an increasing workload for theCouncil and a need for structures to be put inplace to support and encourage ourdevelopment.

I would just like to highlight a few areas andactivities which you will find described inmore depth in other reports. Our finances arehealthy under the watchful eye of Dr Michael(fiscal prudence) Fried. This, I believe, isvery important and a certain small reserve isnecessary to cover potential financialdifficulties in the unlikely event of any of ourmeetings being less financially successful thanin the past. This reserve also gives us thepotential to broaden some of our activitieswhen required.

The SICS Audit Group (SICSAG) has been thebackbone of the Society for many years. Thedata which the audit produces underpinsnearly all discussions the Society hasregarding intensive care activity in Scotland.Simon MacKenzie and Fiona McKirdy are to becongratulated on their hard work. The last yearhas seen some changes in personnel. Furtherchanges are also afoot. A move to come underthe umbrella of ISD is under discussion andsome loss of autonomy may be the price to bepaid for a more secure funding stream. Thegovernance of the audit is also underconsideration. Further consultation with ourmembers will be required in deciding thefuture direction of the audit, with process aswell as outcome being prominent. The futureof care bundles remains a subject fordiscussion. The strength of SICSAG, as

always, has not been in uniformity but in thecohesion and collaboration of all ourmembers. It is an excellent example forScotland of small being beautiful.

Many of you will have noted from the websitethat the SICS guidelines on Activated Protein C(APC) have been withdrawn and have nowbeen superseded by NICE guidelines. Theaudit group are also about to embark on alaision with the Scottish Audit of SurgicalMortality (SASM). Firstly they hope tobecome involved in developing the paperworkwhich will allow the audit of the intensive careof those surgical patients who die and areaudited by SASM.Secondly it is also hopedthat the group will collaborate in thedevelopment of surgical governance reportsand a pilot of such a scheme is likely to be setup.

Tim Walsh has demonstrated an admirableCollegiate and inclusive approach in thecritical care trials group and the group isshowing a willingness to embrace and learnfrom models in the not so new world ofCanada, Australia and New Zealand. Thetrials group have arranged a meeting, againthis year, in June and the programme lookstop drawer.

The major focus of our year’s activity was, asalways, our meeting in Bridge of Allan inJanuary. Record numbers attended and, infact, it is likely we will have to seek a newvenue for the coming year. John Kinsella,Tim Walsh and Sandy Binning did sterlingwork in organising this meeting which was aresounding success. We were well supportedby the Trade and Jeanette McBride deservesour gratitude for all her hard organisationalwork. Sandy Binning has also been the localorganiser of the Spring meeting of the ICSwhich has just taken place in Glasgow. Thishas also been a great success. Well doneagain Sandy. Liz Wilson takes the credit fororganising the successful Trainees meeting.

The Education Group under Steve Stottremains active and Graham Nimmo addsclinical simulation as an extra dimension tothe group’s activities. It is likely the group ison the threshold of further initiatives.

The RCA has traditionally had an annualmeeting with the Chief Medical Officer forScotland who at present is Dr Mac Armstrong.The AAGBI has also in the recent past taken

Dr James Dougall

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part in this meeting and this year, for the firsttime, I was asked to represent the SICS. Thisis a small meeting with a very limited agenda.However, the problem of transport of thecritically ill was raised and discussed at somelength. It may be with central support thatthere will be a move towards a national co-ordinated and integrated service. Much, ofcourse, depends on the central direction takenin reconfiguration of our health services. DrMike Fried has been very active this year insecuring proper representation for intensivecare in the development of ambulance servicesand most particularly in the recent aircraftprocurement exercise. He has also beenpivotal in finally bringing to fruition themanufacture of a standardised trolley forpatient transfer in Scotland.

I have been privileged to represent the Societyon the Scottish Transplant Group and also as aco-opted member of the Council of the ICSUK. The ICS was formed in 1974 and is nowa very mature and effective body. We havemuch to learn from the way in which theyinteract with the Royal Colleges, IntercollegiateBoard and Government regulating and advisorybodies. They have been involved indiscussions about non-medical practitioners,outreach, integrated manpower planning. Inmany ways the lay representation on CRITPALis a very effective way of having the voice ofthe Society heard. The voice of patientscarries much extra weight. It is hoped toseparate the Scottish data from the ICSmanpower census which is currently takingplace and I would encourage you all to co-operate with that as it will help Scottishintensive care.

Mo al Haddad has kindly agreed to take on theupdating and modernisation of our website.This is an important first point of contact formany people with our Society and I amgrateful to Mo for taking this on. Log on andcheck out Mo’s improvements.

It is good to see the regional intensive caregroups continuing to flourish as it is fromthese groups that our regional representationsprings.

It is with great sadness that we heard of thedeath of Dr Greg Imrie. Greg was a verysenior officer in Aberdeen intensive care andwas a stalwart supporter of our Society at itsinception and during its early years. He willbe greatly missed both for his direct nononsense approach, his sense of humour andas a companion on the golf course.

On a more cheerful note we are very pleasedto see Steven Cole return from illness. Howanyone as fit as Steven could become illremains a physiological conundrum.

Until this year Fiona McKirdy was our onlyHonorary member. As proposed a the AGMDrs. Mike Telfer and Peter Wallace have beenoffered Honorary membership and I am verypleased to say that both have accepted.

Our Society will hopefully remain the focus forall the energies of the many active intensivistsin Scotland. This should be especially true ofthe younger cohort who have benefited frommore directed training in Intensive CareMedicine. The SICS is vibrant, new blood iscoming in all the time and our progress issteady and sure.

Dr James DougallPresident , Scottish Intensive Care Society

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annual scientific meeting

Once again the familiar environment of theStirling university Pathfoot Building was thevenue for the SICS Annual Scientific Meeting.

Professor John Marshall of Toronto GeneralHospital, and Canadian Critical Care TrialsGroup fame, was first on the podium to delivera presentation entitled “New Insights intoSepsis”. After epidemiological data on theimpact sepsis has in the USA , where it nowrivals acute myocardial infarction as a majorcause of death, he put forward his question. Isinfection or the host response to blame for allthis? A mouse model of transgenic micefollowing bone marrow transplant showed thata certain allele configuration could conferimmunity from lethal bacteriallipopolysaccharide infusion. Studies haveshown that the degree of host response has abetter correlation with outcome than the typeof infection. There are over 300 allelesresponsible for the neutrophil response toinfection. It is therefore no surprise thatresearch has shifted to understanding the hostresponse and potential targets for therapy.

There have been 53 clinical trials targeting thehost response. The identification of patientsnot mounting an appropriate adrenocorticalresponse to sepsis led to the success ofcorticosteroid replacement during septic shockin reducing mortality. The association of thehost inflammation and coagulation cascadesled to the discovery of the importance ofprotein C in the response to sepsis. ThePROWESS trial showed that recombinanthuman activated protein C given to patientswith severe sepsis resulted in an absolutereduction in mortality of 6%. However, wewere also reminded of the recent earlytermination of the ADDRESS trial whichshowed no benefit for patients with sepsis andan APACHE score less than 25. Lesssuccessful trials have included those looking atnitric oxide synthase inhibitor and anti-TNFtherapy.

Given the heterogeneity of sepsis and the hostresponse the most appropriate method ofclassification is also unclear. For 2 decades wehave used the Systemic InflammatoryResponse System(SIRS) which identifies thehost response without any reference to thepart played by the infection. The PIRO system- an acronym for Patient characteristics, typeof Infection, host Response and Organ

dysfunction – looks at both host response andinsult and might be more useful for casedefinition. Patient characteristics such asgenotype have been shown in twin studies tohave a profound effect on sepsis mortality andcertain gene polymorphisms have beenidentified that are associated with improvedoutcome. Studies at present use the hostresponse to define septic patient groups suchas the APACHE score for rhAPC and ACTHresponse for steroid administration in septicshock. Organ dysfunction scores have alreadybeen used for patient selection in sepsistherapy studies, such as anti-TNF therapy andmore recently rhAPC.

The future of research into sepsis depends ondedicated investigator led research,international collaboration, new RCT modellingand more transparency from thepharmaceutical industry.

Dr Andrew Bodenham, of Leeds GeneralHospital, was next with his personal view on“Safer Central Venous Access”. An earlyreminder of acute complications related toinsertion and maintenance of central venouscatheters(CVC), included figures from the USAwhere a recent study found a morbidity of7%,increased length of stay of 4 days andincreased costs of $17,000 associated withpneumothoraces following CVC insertion. Anobservational study in Leeds showedprocedural complications were not recognisednor documented and were related to operatorinexperience, poor facilities and patientsuffering. Good clinical practice should beensured by appropriate education, facilitiesand specifically the use of ultrasound directedaccess.

This latest note would dominate the rest of thetalk. NICE UK has recommended routine useof ultrasound for central venous access andevidence-based medicine for internal jugularaccess has shown decreased failure rate,complications, costs and time when performedunder ultrasound visualization. A frighteningslide illustrated the considerable anatomicalvariation of the relationships of both thefemoral and internal jugular veins, present inthe population. We were then able to see anexample of the speaker‘s technique in a neatvideo display during which we were remindedto use a gentle popping action, rather than anaggressive stab! Since there is a learning curve

Dr Andrew Bodenhamdelivers his view on safercentral venous access

Professor John Marshall ofOntario asks majorquestions about the originof sepsis

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with all techniques we were asked to practisefrequently on all cases and not wait till wehave a difficult case. We also saw howultrasound can be used for access via theaxillary vein. This is safer than the subclavianapproach, but can prove difficult in obese,requires use of longer CVCs and 10% travel upthe neck. The subclavian vein can provedifficult to visualize due to high anatomicalvariability and poor ultrasound windows.Thefinal comment was that anaesthetists are oftensplit into early and late adaptors as seen withspread of the Seldinger technique ,which isnow common practice.

Optimal positioning of the CVC tip was thenext topic Dr Bodenham tackled. Thecomplications of malposition and frequency ofdifferent positions were mentioned withreference to anatomical studies. Therelationship of the common positions to thecarina as seen on chest radiography is wellknown. This might not be enough as thecontact made with vessel walls, theimportance of the tip lying parallel to the walland the effect of patient movement andrespiration can all result in complications evenwith correct position on chest radiograph.

Long-term venous access, although still notformally defined is now more commonlyrequested for oncology or gastroenterologypatients. Anaesthetists are not responsible forinsertion of these catheters in all hospitalswith 42% of UK departments providing aservice and 18% having a formal list. Anunderstanding of the issues related to cathetercare and implications of differences betweenvarious types of catheter are relevant to allanaesthetists and intensivists. Just in caseanyone was thinking what could be so hardabout providing a service we were shownimpressive contrast venography imaging ofgross anatomical distorsion and stenosis of thecentral veins in a patient with several previouslong term catheters!

After the coffee break Dr Richard Beale, fromGuy‘s and St.Thomas‘ Hospitals, gave apresentation on the “Metabolic Control inSepsis”. Metabolic dysfunction is alwayspresent in severe sepsis and metabolicsupport, in the form of glucose control,corticosteroid supplementation and nutrition,is offered to most of these patients onceadmitted to intensive care. Critically illpatients tend to have a high basal metabolicrate, early protein breakdown and decreasedlipid oxidation. This picture is furthercomplicated by gut failure and frequentlymalnutrition. Dr Beale could go on at greatlength on all these topics but today

concentrated on glucose control. The landmarkstudy of Greet Van der Berghe showing tightglucose control results in improved survivaland less morbidity has changed perception ofglucose control in all intensive care patients.The clinical feasibility of tight glucose controlwas a problem requiring training of nursingstaff, input of more resources andperseverance from all involved. The disbeliefamong clinicians stemmed from the differentpatient population in that study from oureveryday practice, fear of biochemicalhypoglycaemia in practice and the initialsupplementation of enteral feed with dextroseuntil enteral feed was established. There wasalso the suggestion that any benefit seen withthe new protocol was a result of higher insulinusage rather than tight control of bloodglucose. This was answered when a logisticregression model showed that it was definitelythe lower mean blood glucose. Referring to therecent surviving Sepsis Campaign guidelines,which he himself was involved in drawing up,he agreed that there was good evidence thatkeeping blood glucose <6mmol/L was morebeneficial than 6-8mmol/L. However he saidthe guidelines recommended control<8.3mmol/L to encourage universal adoptionof glucose control due to the initial problemsmentioned above. Further interest in insulinadministration incritically ill patients has ledto more questions being asked. More work hasshown that high insulin lowers triglyceridesand low-density lipoproteins while raisinghigh-density lipoproteins. The study showedthat mortality was affected by increasing age,a higher APACHE II score and high LDL levels.Survival in critically ill patients has beenshown to be inversely related to the level oflow-mannose-binding lectin and high insulinlevels result in depression of this acute phasereactant. Dr Beale wound up his talk by listingthe practical issues related to the tight glucosecontrol regime including, nutrition, steroidadministration, time to stop regime, when totreat hypoglycaemia and problems with point-of-care glucose monitors.

WorkshopsThis year delegates had a better deal as theycould choose to attend two of four workshopscompared to one from three workshops lastyear.

Dr Paul Murphy, of Leeds General Hospital,dealt with the concept of “Non-Heart BeatingOrgan Donation”. Heart-beating organdonation requires brain-stem death witharound 2000 cases a year and providing 90%of solid organ transplants. This limited poolmust be supplemented , as

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xenotransplantation is not yet a reality, byconsidering non-heart beating organ donation.On the other hand there are 100,000 cardiacdeaths, in the 15 to 64 year age group, and20% of the population are registered organdonors but there were only 73 donors in2003. The results of controlled NHBOD renalallograft program in Leeds shows encouragingresults. Problems faced by NHBOD are theapparent conflict of interest faced by thecaring clinician, uncertain donor potential andunclear legality of all retrieval-directedinterventions. Practical problems during theprocess include definition of the tome ofdeath, coordination of multidisciplinary teams,timing of withdrawal of futile therapy until theretrieval team is present but prolonging agonalperiod for relatives; the necessity of trial ofwithdrawal; tissue typing and aortocavalcannulation before death. The issue ofresuscitiation, from inotropes to advancedCPR, should death occur before retrieval teamarrives. Several other points were mentionedbut Dr Murphy concluded saying that there isa clear desire to donate organs among thecommunity, we must serve the best physicaland psychological interests of our patients.There will have to be more clinical, ethical andlegal progress in this field to guide cliniciansin the future.

Dr Richard Beale, after his morningpresentation, led a group discussion on“Outreach”. To his surprise, a show of handsamong the audience led him to conclude thatCritical Care Outreach in Scotland is lesscommon than south of the border. We knowOutreach has not resulted in less ITUadmissions nor less cardiac arrests. Its role isto foster improved clinical education andcommunication and experienced ITU nursesseem to be involved most often. Dr Beale thentook the opportunity to promote the SurvivingSepsis Campaign sepsis bundles. The mainquestion is which patients and in whichdepartment should sepsis bundle data becollected. Applying the methodology used byRivers et al is impractical so we mustcompromise. Audience participation wasexcellent and most felt ITU would takecharge, funding will be required, continuousaudit is not essential, ITU patients could bescored for bundle compliance first buteventually other departments and the OutreachTeams would have to apply the bundles tohospital patients. Dr Beale accepted thatmeasurement tools would need to be tailoredto each institution and the SSC will giveadvice on changes to the bundles in the future.

The final presentation of the meeting wasappropriately the most entertaining and it was

up to Dr Hugh Montgomery, of UCLH, toconclude with “Genetics in the ICU”. The firstpart of the talk was about the physiology ofhypoxic adaptation in the animal kingdomincluding examples of interspecies adaptationdifferences in ventilatory drive and hypoxicpulmonary vasoconstriction. The topic wastied in with genetics when we were told thatacclimatization boils down to a single allele inmountain yaks. It would not be difficult toimagine that different genotype could affectthe host response to critical illness which isoften intricately linked to cellular oxygensupply. This led to Dr Montgomery presentinghis interesting work on the genetics of therenin-angiotensin system. The angiotensin-converting enzyme genes are known toinfluence physiology, especially minuteventilation and metabolic efficiency. Thegenotype exists as II or DD alleles and theformer is associated with greater oxygenutilization efficiency as the workloadincreases. Studies on healthy volunteersshowing the metabolic advantage of the DDgenotype were remarkable. He wondered if wewould agree that this presented an excuse forthose II phenotypes who failed to improvetheir workout performance despite their besteffort. From the clinical perspective the DDgenotype has been associated with pooroutcome in a few studies. Children withmeningococcal disease had higher mortalityand length of hospital stay; the DD allele wasassociated with increased incidence andmortality from ARDS and DD trauma patientsfared worse too. The implications of genetictests for patient care are diagnostic, prognosticand could determine best therapy. This scienceis developing fast and might soon influenceclinical decisions.

Michael Buttigieg

Dr Hugh Montgomeryconcludes the meetingwith his presentation‘Genetics in the ITU’

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annual research meeting

This well attended meeting on January 24th2005 was not without its technical hitchesand in a change from the programme openedwith a report on the SIGNET pilot study by DrPeter Andrews.

This is a prospective randomised blindedcontrol trial of 500 patients requiring TotalParenteral Nutrition (TPN). The Trial willinvolve four patient groups, selenium only,glutamine only, a combined selenium andglutamine group and a control group. The TPNwill be in a volume of 1500ml, 12g Nitrogenand have 2000Kcal/day. Ideally all groupsshould have a seven-day treatment time,although five days may well be the average.Variability in the groups is the exactdistribution of the amino acids in the TPN dueto the need for it to be isonitrogenous. Theoutcomes to be measured will be mortality inICU and at six months, episodes of newinfection, antibiotic use, length of stay,assessment of quality of life and ICU costs.Subgroup analysis will include: speciality(medical vs. surgical), age (<65, 65 and over)and level of nutrition (undernourished, normal,obese).

The pilot study involved two sites and twentypatients and served to assess recruitmentmethods, randomisation, data collection,staffing requirements and delivery of trialnutrients. In terms of recruitment 60% ofeligible patients were recruited. No problemswith randomisation and data collection. Thelevel of information collated appears to beabout right and comprehensive. Mainproblems were discussing recruitment withrelatives and subsequent follow-up. Therewere initially problems with supplies of thetrial nutrition. In the pilot 50% of patients hadepisodes of new infection.

An application to the MRC for funding hasbeen submitted. Some funding may come fromFresenius Trials. Recruitment time for 500patients in 9 sites will be 2.5 years.

Dr Tim Walsh then gave an update on TheResolution of Anaemia after Critical IllnessStudy (TRAC)

This is a prospective exploratory study into thetime to recovery from anaemia associated withcritical illness and what factors limit therecovery time. The primary outcome is thetime period between ICU anaemia and

resolution of anaemia. Thirty patients wererecruited, the inclusion criteria requiring thepatients to have a haemoglobin level <10g/dLand having required level 3 care for greaterthan 24 hours during their stay. Patients werereviewed on weeks 1,3,6,9,13, and 26. Datacollated included Hb levels, Fe, B12 andFolate levels, erythropoetin response and IL-6levels and each patients transfusion history.Overall, patients showed a variable butconsistent rise into normal levels ofhaemoglobin. At week 1 some patients’anaemia had resolved, yet they still exhibit aninappropriate erythropoetin response. Irondeficiency is present but acutely this is difficultto interpret. No patients had a B12 or Folatedeficiency. At three months 40% of patientshad Hb <12 g/dL with 18% still <10g/dL.Further study is required and proposed to lookat functional ability of patients during criticalillness, and if being anaemic stops a patientfrom surviving critical illness.

Dr Brian Cuthbertson then reported on a Pilotstudy looking at Fluid loading and Highdependency Care for High Risk Surgicalpatients.

This proposes to look at two systems of HighDependency care and fluid loading onoutcome, in high-risk surgical patients. Theplan is for a multi-centred prospective study,of greater than three centres. The processinvolves a baseline quality of life assessmentand recruitment to the study; the patientsundergo pre-operative fluid loading and thenare randomised to either level 1 or level 2 postop care for 48 hours. Grade 4 Cardiac patientswill be excluded.

The patients are centrally randomised. Theprimary outcome measure is quality of life.Secondary outcomes include 30-day mortality,major morbidity, costs to NHS, QALY cost topatient and family. The primary outcomemeasure is made by the SF-36 at 1-month, 3-month and 6-month intervals.

In the pilot study 150 patients were assessed,of these 40 were high risk. 25 were recruitedto fluid loading, and a further 24 of those wererandomised to the second stage i.e. eitherward or HDU care. 23 survived hospital but 2were removed from the study by clinicianrefusal. The conclusions are that the protocolis safe and acceptable.

Another full house for theAnnual Research Meeting

Lesely Morgan publicisesthe TracMan trial

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The final part of the morning sessiondiscussed the future direction of the ScottishCritical Care Trials Group.

This part of the research day involveddiscussion about how as a group the problemsof conducting research could be addressed. DrJ. Norrie presented the work of the Centre ForHealthcare Randomised Trials (CHaRT). Thetrials unit provides access to dedicated stafffor trial management, plus statisticians,research nurses and IT specialists. Theproblems of conducting research include todevelopment of clinical networks, creatingRCT’s and gaining the necessary regulatoryand ethical clearances. In terms of the SICSconducting trials, it has an established clinicalnetwork, easily identifiable potentialparticipants as a group, already collects largeamounts of data routinely and has providedexamples of “best practice “ to date. The mainproblems facing the SICS is a feeling of lack of“ownership” by a funding organisation.Another is the difficult environment to conductresearch in, with a heterogeneous population,difficulty in standardising treatment, problemswith long term follow-up, and the need forlarge populations to answer questions. Dr P.Warner from the Medical Statistics Unit,Edinburgh added the society maybe at adisadvantage by being perceived as a “newkid” to research. It currently lacks a charitablebenefactor. In terms of authorship a Canadianmodel of maintaining the Group as an authorcan reduce friction between clinicians, but isnot encouraged by publishing journals whichprefer one named author.

The debate continued concerning how best todecide what clinical question as a society weshould try to answer, with consideration of theICS method of canvassing members to respondwith a question, then a single pick from themost commonly submitted questions to decideon a particular topic.

A further point was that it may prove difficultto find a question that can be answered by aRCT and that an observational study may benecessary.

Overall, it was felt that this year’s SICS TrialsGroup meeting a decision should be madeconcerning what question should be persued.

In the afternoon 5 Critical Care Presentationscompeted for the Trainees Prize.

1. Jim Ruddy (A Binning) HSV in RespiratoryTract of Critically ill patients

2. Simon Young (Lynne Newman) ShortSynacthen Test and Etomidate in ICUPatients

3. Michael Buttigeig (Magnus Garrioch) ICUSurveillance of Infection Study

4. S. Manawarthe (A Longmate) Hospitalacquired Infection in ICU

5. Paul Campbell (A Davidson) ICU DrugBudgets

The First Prize went to Dr Paul Campbell for apresentation on rationalising the drug costs oftwo ICU’s in a single Trust Division and thepotential savings this can provide. SecondPrize was awarded to Dr Simon Young for astudy of the effect of Etomidate on ShortSynacthen Tests in critically ill patients.

The Principal Speaker of the day was ProfessorJohn Marshall, Toronto, Canada – President ofthe Canadian Critical Care Trials Group

Professor Marshall gave a review of thehistory, ethos and work of the CCCTG. Fromits inception in 1989 it has tried to fostermulticentre research and provide a venue foreducation in research methodology. TheCCCTG has three meetings a year split acrossthe country and has an association with theCanadian Critical Care Society. The CCCTGhas an ongoing policy of protocol reviewwhereby a new study is critiqued in terms ofthe clinical question it hopes to answer, theassociated abstract, the proposedmethodology, plans for pilot work, funding andexecution. Ongoing studies are reviewedperiodically for progress and future plans.

Some of the studies undertaken include stressulcer bleeding rates and prevention,Withdrawal of Life Support issues and rates,PROTECT study comparing unfractionated andLMWH in prevention of VTE, ABLE study (Ageof Blood Evaluation) and the effects of olderblood on mortality rates, to name but a few.Professr Marshall outlined that in his opinionthe main reasons for the CCCTG’s success hasbeen related to focusing on questions thatclinician’s want answered, fostering agenerous collegial mentality, maintaining thereview and mentoring process, utilising aprogrammatic model of research and avoidingpharmaceutical involvement. The challengesfacing the Group will be gaining sustainablesources of funding, improving education andmentoring, increasing the membership,developing international collaborations andinvesting in research about research. Hethanked the SICS for the invitation to speakand wished the Society every success for thefuture.

Paul Harrison

Professor John Marshall ofToronto, principal speakerof the day, reviews thehistory of the CCCTG

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annual spring meeting of ics uk

This years Annual Spring Meeting took placein Glasgow. The two days of lectures followedon from the skills for intensivists day and theearlier trainees meeting. 300 delegatesgathered in the famous Scottish Exhibition andConference Centre to hear a wide collection ofworld experts, network amongst peers andcatch up on the latest research andinnovations.

The SECC, the so called Armadillo, representspart of the continued development of theformer shipyards and for a few minutes eachyear manages to catch the sunset for the nowubiquitous photographs. My last visit to theSECC had been to Kylie’s Showgirl tour theprevious month. Aside from the extravagantcostumes and meticulous choreography, thiswas an outstanding address by one of theleaders in her field. I wondered if the ICScould compete?

Not all delegates who arrived at the firstsession had joined the 7am charity fun runalong the river. The session on comprehensivecritical care kicked off the meeting. Prof Joyntfrom Hong Kong presented some work fromhis unit that perhaps reassuringly providedevidence that intensive care units do providean outcome benefit. The evidence base foroutreach was reviewed by Dr Cuthbertson(Aberdeen) who firmly argued that outreachdoes not work and that intensive care unitsshould be with secure walls and running tocapacity. From those four walls however, theregistrar must emerge to join the hospital atnight team; Dr Coakley (London) spoke of his,largely positive it seems, experiences of theseand emphasised the large culture shifts theseset-ups must entail.

A parallel session on the airway in intensivecare ran after coffee. Dr McCloskey (Belfast)explored the potential problems that we runinto in the process of intubating our ITUpatients and how this differed from the theatreenvironment. Once intubated, means ofpreventing ventilator-associated pneumoniawere discussed by Dr Swan (Edinburgh). Muchof the evidence for these, and much else, isavailable on the Scottish Intensive CareSociety web site (www.sicsebm.org.uk) ineasily digested reviews (CATS).

A generous lunch allowed for perusal of theposters and trade stands as well as thesurviving sepsis campaign symposium. With

bright lunch boxes balanced on knees weheard the basis of the bundles, thepracticalities of their implementation andperhaps for some, ammunition for the debateon friday. The research and clinical practiceposters were to a high standard with theauthors keen to engage in further discussions.The varied trade representatives impressedupon us the continued innovation anddevelopment at a corporate level, including,for example, an external lung driven by thepatients own cardiac output.

The afternoon was split initially to parallelsessions on non-invasive ventilation andelectronic ITU. The take home from the NIVsession was that when NIV works, it workswell. There are outcome benefits and that itsscope may broaden.

Headline act, Prof Gattinoni (Milan) addressedthe whole conference on ventilation in ARDS.This included discussion of much of thebackground to current ideas, a lot of whichwas established in the 1970s; as well ascurrent thoughts and controversies. To roundoff the first day, the recently retired Dr Wallace(Glasgow) returned from the golf course toentertain us all with his many experiences,good and bad, of over 30 years as a leadinglight in intensive care medicine.

The annual dinner that first evening must havebeen a success for the number of glasses ofwater circulating first thing. The morningsession on infection considered bacterialresistance to cephalosporins; ways to preventcentral line infections and the microbialecology of the ITU. These humbly reminded usthat we are not the only ones at home in ourITUs. Professor Joynt shared his first handexperiences of the front line of the recentSARS outbreak and the profound effect that ithad on all those involved.

Four abstracts had been selected fordiscussion by their authors. Dr Cadamy(Glasgow) presented his data on therelationship of b-type natriuetic peptide on ITUmortality and explored some of the potentialavenues for his work. The prize-winningpresentation by Dr McKechnie (Edinburgh)was his research on the effects of hyperoxia ontrans-differentiation of alveolar epithelial cells;his immunfluorescence techniques certainlygave very dramatic slides.

The famous Armadillo inGlasgow, location of

Annual Spring meeting ofthe Intensive Care

Society UK

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Surgical colleagues Dr Ramsay (Maastricht)and Mr Carter (Glasgow) discussed themanagement of acute severe pancreatitis. Therecent consensus expert guidelines on thisprovided at least a foundation for thediscussion, but we witnessed that debate onmany aspects of the treatment of pancreatitisis very much active.

The final two parallel sessions were on lifeafter ICU and hot topics. In hot topics weheard from Prof Singer (London) that the PAC-MAN study had just been accepted forpublication and there was not a differencebetween the two groups. The polyneuropathyof critical care is likely to be underestimatedand is of unclear causation according to Prof

Hinds (London). The meeting rounded off witha debate on whether to adopt the survivingsepsis bundles. Both Dr Beale and Prof Singerargued their cases with skill and wit andperhaps the same inter-unit rivalry exists inLondon as it does in Glasgow!

So on reflection, costumes may be lacking butthe meeting was meticulously choreographedand we heard many world leaders sing, acredit to the organisation of Dr Sandy Binningand the rest of the ICS team.

Richard Price, SpR, Western Infirmary,Glasgow

west of scotland intensive caresociety report

The year started with a change in personnelleading the Society. Dr Brian Cowan completedhis tenure as President, as did Dr Phil Oatesas Secretary. Both take with them thegratitude of the Society for their work andsupport.

Dr John Kinsella took over as President, DrRory MacKenzie joined the Committee and Itook on the responsibilities of Secretary.

The Society has had a good year with anincrease in membership and good attendancesat the meetings.

The first meeting of the season was “IntensiveAftercare After Intensive Care” from Dr CarlWaldemann from the Royal BerkshireHospital. He gave an excellent insight intotheir post intensive care support and clinicprogram. This is an extremely topical area,although one which has not been addressedextensively in the West of Scotland.

As is usual the second meeting in Februarywas the Registrars’ Presentation. This year wehad 5 entrants, all of whom presented theirwork to the Society. Dr Andrew Cadamy fromGlasgow Royal Infirmary won first prize for hispresentation: Brain Natriuretic Peptide: auseful marker… or just another ‘serumrhubarb’?

The third and final meeting of the year isscheduled for May 24th when ProfessorBellamy from St James University Hospital

will address the topic of liver failure. This is adisease which we are all very familiar withhere in the West. The AGM will be held afterthe meeting.

The Society’s Travelling Fellowship has beenawarded to Dr Andrew Cadamy to enable himthe travel to Aarhus University Hospital inDenmark to study the use of transthoracicechocardiography in the ICU there. We lookforward to hearing his report next February.

Meetings are open to all staff involved inintensive care, members and non-membersalike. There is complementary buffet prior tothe meeting, a CME point during and, usually,an optional beverage at a local hostelryafterwards.

Membership enquiries should directed tomyself.

Malcolm BoothConsultant Anaesthetist, Department ofAnaesthesia, Royal Infirmary, Castle Street,Glasgow G4 0SF

Telephone: 0141 211 4620

email: malcolm.booth@northglasgow.scot.nhs.uk

12

south east scotland ITU group

There were several changes in personnel overthe year. Dr Bob Malcolm (Queen Margarets,Dunfermline) took over as SICS representativefrom Mike Fried. Dr Brian Cook (RoyalInfirmary, Edinburgh) replaced AlasdairMacKenzie as Treasurer.

As in previous years a series of meetings werehosted by the individual departmentsthroughout the region. The focus had been toencourage greater trainee participation from a“wider” background of parent specialities. Thisproved to be moderately successful withgreater attendances and increased enthusiasmand approval (via informal feedback).

The first meeting at the Western GeneralHospital involved Dr Ian Grant giving anerudite review on the “difficult to wean”patient, including considerations made for theinitiation of home ventilation. St. JohnsHospital presented several interesting cases

and discussion ensued on the use (and timingof use) of vasopressin in catecholine–refractoryshock.

The Royal Hospital for Sick Children hostedthe next meeting – presenting several casesrelating to the general theme of severeinfections. Professor Emili-Milic from Montreal(a mentor of Gordon Drummond) wassponsored by the group in delivering a lectureat the Royal Infirmary considering whatlessons from physiological research into COADcould be applied to acute lung injury.

Dr Tim Parke from the Southern GeneralHospital, Glasgow gave the final talk of theyear examining potential changes to the earlymanagement of patients with suspected sepsisin the Accident and Emergency Department. Avigorous and illuminating discussion ensuedthereafter.

David Semple

scottish intensive care societyaudit group report

Annual Audit MeetingThe Society’s 10th Audit Meeting was held on12th November 2004 in the Education andConference Centre, Stirling Royal Infirmary.The 100-strong audience had the privilege oflistening to Professor Mitchell Levy, RhodeIsland, who was our guest, internationalspeaker. His contribution to the meeting wasexcellent; firstly, presenting the SurvivingSepsis Campaign, participation in which ICUsin Scotland must investigate and discuss. Wewere fortunate to have Mitchell finish the daywith a very thought-provoking presentation onEnd of Life Care.

As well as welcoming the delegates, SimonMackenzie gave an overview of audit activitiesand the Annual Report. He presentedsuggestions as to the possible future work ofSICSAG, including the application of the‘Sepsis Care Bundle’. The sepsis care bundleshave been tested in the Royal Infirmary ofEdinburgh and some very positive results from

this were presented by Julia Critchley, a 4thMedical Student who had worked on thebundle with Dermot McKeown. During Simon’sreview of the Report, Louie Plenderleithstepped in and described the introduction ofStatistical Process Control to data analyses asa means of assessing clinical outcome.

Gill Harris presented an update on the level ofparticipation of HDUs in the audit. She wasable to present comparative results on HDUs’activities for 2002 and 2003. The HDUnursing staff were praised for their continuedinterest in the HDU audit, which they conductwith little support from medical colleagues.There were discussions about the changes tothe minimum Augmented Care Period (ACP)dataset, which will better address descriptionof HDU activity as well as enable objectiveclassification of levels of care in both ICU andHDU. The modifications are well underway onthe audit software, as detailed by Brian Millar(Critical Care Audit LTD, Yorkshire). Brian also

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updated the audiences on the changes to forthe surveillance of hospital-associatedinfection and Malcolm Booth reminded usabout this important study.

Over the last few years there has been anincrease in the number of Outreach teams andintegration of early warning scoring systems invarious hospitals. A very informative andinteresting session on early warning scoringsystems generated animated discussion. IanThomson (Outreach and Shock Team Co-ordinator) reviewed North Glasgow UniversityHospitals’ experiences of MEWS, including theprocess involved and the audit results.Implementing early scoring systems in acutemedicine has so far been challenging. TheNHS Quality Improvement Scotland IllnessSeverity Scoring Subgroup has, however,developed and piloted an early warning scorein acute medicine in Lothian. The background,process and results of this pilot werepresented by Ruth Paterson (PracticeDevelopment Nurse, Lothian). Crucially, theresults in these presentations demonstrated asignificant increase in documentation ofphysiological parameters and a reduction inmortality post-introduction of the charts. Animportant point Ian and his colleague, JudithRoulston, made was the requirement forcontinued support and monitoring to maintainmomentum of ward staff. That the earlywarning tools described by Ian and Ruth (aswell as those implemented in other hospitals)varied slightly was not seen as detrimental;the mere fact that there is a process in placethat encourages greater recording ofphysiological variables, enhances earlyrecognition and prompt, appropriate treatmentis the most important feature of early warningtools.

Evaluation of the meeting was very good.

Date for your diary: Annual Audit Meeting,Friday 28th October 2005.

Annual ReportThe Annual Report was published inSeptember 2004. As well as reporting onICUs’ activities, we conducted an in-depthreview of the transfers of patients to ICUs,overall, within NHS Boards and across NHSBoards. We continue to work with ScottishPharmacists and reported on the variation inthe use of, and expenditure on, sedative andneuro-muscular blocking agents in 16 ICUs.For the first time, we presented outcome datain the form of a Statistical Process Controlchart. Copies of the report were available fordelegates at the Annual Audit Meeting and anelectronic version was included on a CD-ROM

in each delegate’s pack. A series of graphswere compiled for each ICU’s data thatcomplemented the national data described inthe annual report. Each series of slides wasemailed to the ICU consultants and nurses forwhom the audit group has email address. Amemo containing the unit’s identifiers for theanonymised data in the Report was includedin the email. The Report is available to read ordownload from the website.

Ward Watcher ModificationsChanges have been made to reflect thedynamic nature of the audit. The mainmodifications are summarised below:

• Augmented Care Period dataset (ACP):Previously agreed modifications to theACP dataset have been made and aregradually being installed around Scotland.The ACP changes reflect the need for asingle dataset which accommodates boththe ICU and HDU audits’ needs and therequirement to describe case mixaccording to standard definitions (levels ofcare).

• ICU-Associated Infection: SICSAG hascollaborated with Health ProtectionScotland (formerly, Scottish Centre forInfection and Environmental Health) forthe last few years to design an ICU-associated infection surveillance systemusing the national audit software (WardWatcher, Critical Care Audit Ltd.,Yorkshire). Ward Watcher has now beenmodified and contains a criterion-baseddataset compliant with an Europeaninitiative, Hospitals in Europe Link forInfection Control through Surveillance(HELICS). The program been recentlyupgraded in 6 ICUs: Glasgow RoyalInfirmary, Ninewells Hospital, RoyalAlexandra Hospital, Royal Infirmary ofEdinburgh, Western Infirmary andSouthern General Hospital. These unitswill be pilot sites to test the feasibility ofconducting the HELICS surveillance inScotland using Ward Watcher. There havebeen very positive responses to the easeof use of Ward Watcher for thissurveillance. Other sites have expressedinterest in the surveillance and it is hopedthat they will participate in the future. Thesurveillance will enable comparison ofScottish data with other European ICUs.

• SICS Diagnoses: In 1999, the Societyintroduced a more comprehensive,common diagnosis list, hoping that aclearer picture of problems requiringintensive care would be available. A

14

review of the list and identification ofmissing diagnosis from the ‘Other’selection was carried out last year. The listhas been updated to make it moreinclusive and will be gradually updatedacross the units.

• Removal of Extraneous Datafields: Thelatest version of Ward Watcher has alsoseen the removal of extraneous datafields.These include the fields used in the pastby the Mortality Probability Model (MPM)II at admission and at 24-hours (middlesection of history screen and severityscreen fields). Remnants of theprospective sepsis study conducted in2002 (fields on the ACP screen) have alsobeen removed.

SIGNET (Scottish Intensivecare Glutamine or seleNiumEvaluative Trial)MRC funding for Scotland’s first randomisedclinical trial in intensive care has beengranted. Paramount to this award was thealready established ICU audit network and ourtrack record of international publications. TheTISS data that were collected in the ICUsduring 1999-2000 were instrumental indetermining the extent of parenteral nutritionin Scottish ICUs and, along with the length ofstay of these patients recorded in thedatabase, was instrumental in powering thestudy.

HDU AuditThere are currently 27 HDUs in which thenursing staff diligently continue to collect data.Welcome to Gilbert Bain Hospital in Shetlandin which data collection began this year. Six-monthly reports on each unit’s activity during2003 were produced and distributed to theunits as well as a summary of their activitythroughout 2003. Subsequent discussionsrelating to the content and relevance of theinformation contained within the reports havebeen positive.

Data validationHigh quality data collection is very important –the results from the data are used bothclinically and managerially. Gill hashighlighted ‘age’ errors, a result usually ofrecording an incorrect year of birth – often thisis at the turn of a year. This error will bereduced by improvements in the forthcomingWard Watcher upgrade, however, weencourage your continued attentiveness duringdata entry.

StaffGill Harris left the SICSAG in March 2005. Wethank her for her hard work since November2001 and wish her well in her new post andher continued active duties as Captain Harrisin the Territorial Army.

Contact usAs always, if you have any queries, pleasedon’t hesitate to contact the audit group staffby phone or email.

SICSAG, Queen’s Park House, VictoriaInfirmary, Langside Road, Glasgow G42 9TY.Telephone: 0141 201 5271.

http://www.scottishintensivecare.org.uk

Fiona MacKirdy

Project Director

15

education committee report

The annual intensive care course is now partof the year calendar. Originally there wasthree courses a year rotating around differentareas in Scotland but recently to matchdemand there is now the one annual coursewhich is held in Stirling. For the first timelast year the course was organised by theintensive care trainees, very ably led by MoAl-Haddad and supervised by MartinHughes. It was a resounding success interms of numbers attending, educationalcontent and (very importantly to me)financial balance. The numbers wereincreased by very good publicity and alsomaking sure allied health professions werewell represented. This produced a very goodmix of skills and opinions for the course andmade the small group work especiallyrewarding. The books were balanced bymaking very good use of pharmaceuticalsponsorship while making sure that duringthe course their presence did not overwhelmthe delegates. This is a trend that is verylikely to continue as the cost of hiringsuitable venues continues to rise. The nextcourse is again being organised by thetrainees with Mike MacMillan leading and isto be held on the 25th and 26th of August.Please let all on your units know about it. Itis still very good value for money !

The other work of the committee this year ison induction for trainees who are startingintensive care for the first time. We are goingto be contacting all units in the very nearfuture to gather information on what is alreadyout there and hope to collate this informationto produce guidance on what trainees shouldbe inducted with when they start theirintensive care careers. Please feel free tocontact us with any ideas that you may have.

Finally, as last year, we are always looking fornew members of the group. So, if you feel youwant to get involved please get in touch.

Steve Stott

Chair, Edcuation Group

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scottish critical care deliverygroup chairs’ forum report

The group continues to be active, meetingtwice a year – lately at St John’s Hospital,Livingston. Geographically disparaterepresentation continues from Shetland toDumfries. Close collaboration continues withthe SICS, the SICS audit group and the SEHealth Department. The principal topics ofdiscussion have been:

1. SICSAG: the importance of thecontinuation of both the HDU and ITUaudits was stressed.

2. Acute service reconfiguration: this isaffecting and will affect all parts of thecountry. Changes have occurred in Fife,Inverclyde, Vale of Leven, Forth Valley,Tayside and West Lothian. Reviews areoccurring in Lanarkshire and GGHB. Thechanges have a direct effect on criticalcare services. Transport of the critically ill(secondary transport) becomes a live issue(see separate report).

3. Outreach and patient at risk scoringsystems: outreach has not beenuniversally adopted not due to the lack oftrying but because of the resourceimplications. A new group has been

established - Critical and acute careoutreach interest group for Scotland(COGS) at which Dr Nigel Leary is our linkperson. Other areas use early warningscoring systems (e.g. MEWS and SEWS).

4. Winter pressures: the under provision oflevel 3 (average occupancy acrossScotland is >80%) and surgical level 2capacity continues, although we havebeen able to accommodate the 2004/5winter pressures. Medical level 2capacity remains a challenge with theearly signs of improvement in somehospitals.

5. I am coming to the end of my 3 year termand by next year we will have a new chair(so this will be my last report!)

In summary the group remains active withgood and representative participation. Active“cross pollination” with other organisationssuch as the SICS and SEHD continues.

Mike Fried

Chair, Scottish CCDG Chairs’ Forum

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scottish transplant group report

The drive to increase the numbers of organdonors continues. Advertising campaigns inthe media to increase population awarenessand family discussion have taken place overthe year.

The pilots of non-heartbeating donation havebegun in the Southern General Institute ofNeurological Sciences in Glasgow and in TheRoyal Infirmary, Edinburgh. It is hoped theywill produce a modest increase in donors asindicated in a pre-launch audit.The SingleOrgan Retrieval Team was officially launchedon the same day last October,and so far isproving popular with anaesthetists andintensivists.This is consultant lead and will becarefully audited during this first year.Bothnumbers of organs and their quality afterretrieval will be considerations in a rathermore complicated evaluation of the future roleand sustainable configuration of this service.

Both the Intensive Care Society and the BritishTransplantation Society have producedupdated guidelines this year and are availableon their web sites.

Another group under the Chairmanship ofPeter Simpson is looking at revision of thecriteria for the diagnosis of death by brainstem testing ( the yellow book ) and also byconventional cardio-respiratoryexamination.This is more complex andcontentious than it would appear at fistsight.Hopefully they will report in the nextyear.

It remains important that we continue to havea voice in the developments

Dr James Dougall

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scottish transport of the criticallyill group report

This is a multidisciplinary group (ITUconsultants and nursing staff and the ScottishAmbulance Service (SAS)) with geographicalrepresentation from across Scotland. It wasset up under the aegis of the SICS and theSAS. Its remit is to act as a forum for theexchange of ideas between clinicians and theSAS, the design of a critical care trolley, theformulation of advice to be offered to the SAS,SICS and SEHD on matters of transport, whichis gaining progressively greater prominencedue to the centralisation of acute services withthe clear repercussions that that has for theSAS.

Achievements1. The design and development of a new

critical care transport trolley (CCT): thishas been the result of a solid teamapproach with close collaborationbetween the SAS, the trolley manufacturer(Ferno) and the clinicians (in particular DrPeter Curry, Dunfermline). The trolley isnow available for clinical use. The SAShave given an undertaking that it will fit inmost front line ambulances by next year.Currently all ambulance stations have atleast one vehicle which will accept thetrolley. The trolley is secured within theambulance in seconds! The aim/hope isfor the trolley to become the standard CCTacross Scotland. The CCT costs £6995(exc VAT) and is available from:

Ms Andrea Farrow

Ferno (UK) LtdFerno HouseStubs Beck Lane, CleckheatonWest Yorkshire BD19 4TZ

Telephone: 01274 851999

e-mail: AFarrow@ferno.co.uk

Any questions or problems don’t hesitate tocontact myself: mike.fried@wlt.scot.nhs.uk

2. We have successfully taken part in theSAS’s air reprocurement exercise consultationand Drs George Smith (Aberdeen) and

Catriona Barr (Shetland) are our “linkmen” inhelping to design the new air ambulanceservice which is due to “take off” in 2006.We are also working on the air/land transportinterface which is currently so frustrating.

3. We are currently in active discussions withthe SAS and NHS National Services unit intrying to address the question of how we bestdeal with the secondary (inter-hospital)transport of the acutely ill patient – therequired infrastructure (co-ordinating centre,dedicated vehicles, trolleys) and the muchmore difficult staffing implications (ambulancedrivers and medical retrieval teams).

In summary we are busy!

Mike Fried

Chair, Scottish Transport of the Critically IllGroup

19

sics evidence-based medicinegroup report

2004 has been a very productive year for theEBMG. There was a significant increase inpublications compared with previous years.Five reviews (Therapeutic Hypothermiafollowing OOHCA, Making Changes ToPractise, Prevention of Ventilator-AssociatedPneumonia, Guillian-Barre Syndrome, InhaledNitric Oxide and Prone positioning in ARDS)and eleven stand-alone paper reviews werepublished on the groups website(www.sicsebm.org.uk). This represents a totalof 47 newly published critical appraisals,bringing the total published by the group to-date to 80, by far the largest collection ofcritical care appraisals available on the webtoday.

The website had grown in popularity over thelast year. It currently attracts over 5,000visitors per month. This has lead to a steadyrise in the websites world wide rankings withthe webs major search engines. Currentlywhen searching under “evidence basedintensive care” the site ranks 1st (Google), 2nd(BT.Yahoo), 3rd (AltaVista) and 5th (Yahoo).This reflects well the large amount of work putinto the website by many of the group.

There have been several other modifications tothe site over the year: a feedback facility,automated updates and a download section.

September 2004 saw the launch of the groupsautomated email updates. All SICS membersshould now receive email updates alertingthem to new publications or website features.This service is also available to non-SICSmembers through the website.

The SICS EBMG and CCTG held their first joint

meeting in June 2004 in Bridge of Allan. Themeeting was well attended by almost 50delegates. A wide range of research and EBMtopics were discussed.

The following projects are ongoing: Nutrition(Marcia McDougal), Hypothermia II (ChrisCairns), Prevention of CVCrBSIs (DavidSwann), NIV (Michael MacMillan), SDD(Muthuswammy Pillai).

As always, the group welcomes submissionsfor publication on the website. All submissionsto the group are now peer reviewed by at leasttwo reviewers. The reviewers are named oneach publication.

Chris Cairns

Chair, SICS EBMG

Five CATS were presented at the EvidenceBased Medicine Section of the Critical CareTrials Group Meeting in June 2005. A prizewas awarded to Anja Beilharz, an SHO fromStirling, for the best presentation. The winningCAT is published here - see pages 20-21.

OOHCA: Hypothermia may improve outcomeOnly a few people sustaining an out-of-hospital cardiac arrest survive with a goodneurological outcome. Systematic review of 3 existing studies (varied in methodology andend-points). For every 6 patients cooled (method varies) one more good neurological outcome(95% CI 4 to 12).Level of evidence: 1- (SR with a high risk of bias: single not multiplereviews, no testing for heterogeneity))

Citation/s: Hypothermia for neuroprotection after cardiac arrest: Systematic review andindividual patient data meta-analysis, Critical Care Medicine 2005;33; 414-418.

Lead author: Michael Holzer, Department of Emergency Medicine, General Hospital Vienna,Medical University of Vienna, Vienna, Austria

Three-part Clinical Question: Does induced mild hypothermia improve neurological recoveryin survivors of primary cardiac arrest?

Search Terms: Hypothermia, Cardiac arrest, therapy

Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, non-English sources, CINAHL, PASCAL, BIOSIS

Study Selection: Included: randomized or quasi-randomized trials 1-3, of adults, who weresuccessfully resuscitated after primary out-of hospital cardiac arrest. Therapeutic hypothermiaapplied within 6 hours of arrival in A+E. Excluded: no control group or historical controls.

Data Extraction: all authors of the identified trials supplied individual patient data with a pre-defined set of variables:

Patients: 3 studies enrolling 275, 77, & 33 patients, adults, comatose after VF/VF/PEA orasystole cardiac arrest, after return of spontaneous circulation

Treatment: induced hypothermia, target temperature < 35°C, 3 different methods (coolingmattress +/- icepacks, icepacks, helmet device), within 6 hours after arrival at EmergencyDepartment after event

Outcome: Short term: good neurological recovery (Cerebral Performance Categories Scale 1 or2) and discharge from hospital. Long term: good neurological recovery and alive at 6 months.

There were not multiple independent reviews of individual reports. They were not tested forheterogeneity.

The Evidence:

clinical care trials group, embsection winning cat

OutcomeTime tooutcome

TypicalCER

TypicalRR RRR NNT

Hospital discharge 0.31 1.68 - 60% - 6

95% confidenceintervals

1.29 to2.07

- 4 to- 12

6 months 0.36 1.44 - 44% -6

95% confidenceintervals

Alive with goodneurologic outcome

Alive with favourableneurologic recovery 1.11 to

1.76- 4 to- 25

Comments:1. Do the methods allow accurate testing of the hypothesis? No, the studies are

heterogenous for patients included (VF/VT cardiac arrest versus PEA/asystole with knowngrim prognosis of the latter), of small sample size (n = 275, 77, & 33). Differentmethods of treatment in each trial (different method of cooling, target temperature,

duration of hypothermia, method and timing of rewarming). Different outcomemeasures and study objectives (one study3 was not designed to assess neurologicoutcome, but to test the feasibility and timing of the helmet device to achievehypothermia).

2. Do the statistical tests correctly test the results to allow differentiation of statisticallysignificant results? Yes, but note 1) and also outcome measure “alive at 6 months” wasrecorded in HACA trial only1.

3. Are the conclusions valid in view of the results? No. See Q1. There must be some doubtover the validity of the results due poor methodology.

4. Did results get omitted, and why? No, on the contrary: 3 patients who were not in theoriginal publication in 2001 were added to Hachimi-Idrissi et al. for the purpose of thismeta-analysis.

5. Did the authors suggest areas of further research? Yes - further research necessary withstandardised methodology and chosen end-points, to determine optimal method ofcooling including duration, and to describe clearly long-term outcomes.

6. Did they make any recommendations based on the results and were they appropriate?The authors suggest that mild hypothermia is effective in improving short-term recoveryand survival in patients resuscitated from cardiac arrest of presumed cardiac origin.However further research regarding the exact method for applying hypothermia isrecommended and a warning not to use hypothermia uncritically in view of possibleadverse side effects is issued.

7. Is the study relevant to my clinical practice? Yes, but again, more due to the 2 largeRCTs rather than this systematic review. Nothing new is added.

8. Level of evidence? 1- ; high risk of bias.

9. What grade of evidence does this study represent alone? N/A.

10. What grade of recommendation can I make when this study is considered along withother available evidence? B

11. Should I change my practice in view of these results? Yes, but because of the 2 largeRCTs.

12. Should I audit my practice: if hypothermia used, then it should be audited with attentionto clinical detail.

Appraised by: Dr Anja G Beilharz, SHO, Stirling Royal Infirmary, Department of Anaesthesia,Intensive Care and Pain Management, Livilands Gate, Stirling FK8 2AU. 15 June 2005.

Edited by CC & MD. Email: anjagbeilharz@doctors.org.uk

Kill or Update By: May 2010

References:

1) HACA, NEJM, Feb 21, 2002, Vol.346: Mild therapeutic hypothermia to improve theneurologic outcome after cardiac arrest

2) SA Bernard et al., NEJM, Feb 21, 2002, Vol.246 : Treatment of comatose survivors ofout-of-hospital-cardiac arrest with induced hypothermia

3) S Hachimi-Idrissi et al., Resuscitation 51 (2001): Mild hypothermia induced by a helmetdevice: a clinical feasibility study

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. Beilharz AG.2005 : Holzer M, et al. Hypothermia for neuroprotection after cardiac arrest: Systematicreview and individual patient data meta-analysis, Critical Care Medicine 2005;33; 414-418.

22

The Scottish Intensive Care Society

The Society is managed by a Council and the office bearers are:

President ................................................... Dr James Dougall .......................... Glasgow

Past president ............................................ Dr Louie Plenderleith ..................... Glasgow

Secretary ................................................... Dr John Kinsella ........................... Glasgow

Treasurer ................................................... Dr Michael Fried ......................... Livingston

Area Representatives and Co-opted MembersWest Area RepresentativesDr Charlotte Gilholly ................................... Royal Infirmary ............................. Glasgow

Dr Malcolm Booth ...................................... Royal Infirmary ........................... Glasgow

Dr Rory Mackenzie ..................................... Monklands

East Area RepresentativesDr Graeme Nimmo ..................................... Western General ......................... Edinburgh

Dr Robert Savage ....................................................................................... Forth Valley

North Area RepsDr Stephen Stott ............................................................................................ Aberdeen

Dr Stephen Cole ............................................................................................... Dundee

Dr Sandy Hunter ............................................................................................ Inverness

Trainee RepresentativesDr Yadhu Rajalingan ...................................................................................... Edinburgh

Co-optedAudit Group Chair ...................................... Dr Simon Mackenzie

Chair of Scottish CriticalCare Trials Group ....................................... Dr Tim Walsh

Evidence Based Medicine Group .................. Dr Chris Cairns

Chair of Education Sub Group .................... Dr Stephen Stott

Meetings Convenor ..................................... Dr Sandy Binning

SICSAG Project Director .............................. Fiona McKirdy

Editor of Annual Report .............................. Dr Philip Oates

Future MeetingsSICS Annual Research Meeting .................... Thursday, 26th January 2006

SICS Annual Scientific Meeting .................... Friday, 27th January 2006

The above meetings will be held at:

Hilton Dunblane HydroPerth RoadDunblane FK15 0HG

23

The Scottish Intensive Care Society

Secretary: Dr John Kinsella, University Department of Anaesthesia, Glasgow Royal Infirmary

www.scottishintensivecare.org.uk

www.sicsebm.org.uk