evidenceBasedCritCare06

evidenceBasedCritCare06 - Evidence-based critical care...

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Evidence-based critical care – Update 2006 Joel Peerless MD 3 January 2006
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Intensivist shortage Experts predict that as the US population ages, the shortage of intensivists will become increasingly acute By 2020, the supply of intensivists will meet only 22% of the demand for their services
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The old way… Intern/junior resident (Dr. X) was taught a concept by his/her: Senior resident Chief resident Fellow Attending Dr. X practiced what he was taught…
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The old way… Dr. X went on to become: A senior resident A chief resident A fellow An attending And taught the same concept to his/her junior resident, and so on and so on….
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The old way…”Why do you do it that way??” “Well, I learned this from Dr. X” “We’ve always done it this way” “We have good outcomes” “I have an article to prove it” (more on this later…)
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The old way… dopamine Dopamine in low doses activates dopamine receptors in the kidney Renal blood flow is increased Urine output is increased (sometimes) The assumption, and teaching, became…
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The old way… dopamine Dopamine is indicated for: Preventing renal failure Treating renal failure Reversing renal vasoconstriction when vasopressors are used Preventing renal failure during aortic and renal cross-clamping Dopamine flowed like water (often better than urine) in ICUs worldwide
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Evidence-based critical care THERE NOW EXISTS A MORE “SCIENTIFIC” METHOD TO PROVIDE CARE…
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The new way… Try to adapt practice based on the quality of clinical studies that support the test or intervention – “Evidence-based” A careful evaluation of existing studies Type of trial Number of centers Number of patients Quality of the study
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Evidence-based concepts The best study is: Prospective Randomized Double Blinded – not always possible Multicenter Meta-analyses evaluate a number of similar studies
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Evidence-based concepts Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock 11 critical care societies - international Initial document: CCM March, 2004 Evidence-based review: CCM supplement November, 2004
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Grading system Grade A: At least 2 large, randomized trials with clearcut results Grade B: At least 1 large, randomized trial with clearcut results Grade C: Small, randomized trials, uncertain results
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Grading system Grade D: Nonrandomized, contemporaneous controls Grade E: Nonrandomized, historical controls; case series; uncontrolled studies; expert opinion
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Evidence-based critical care VENTILATOR MANAGEMENT OF ARDS Vt settings Level of PEEP Use of steroids in “late” ARDS
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Low tidal volume strategy Barotrauma High pressure generated with flow of air into lungs Volume trauma (volutrauma) Overdistention of alveoli can lead to further lung damage
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Low tidal volume strategy Classic practice: Vt 10-15 cc/kg Hypothesis: lower Vt is protective of
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evidenceBasedCritCare06 - Evidence-based critical care...

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