Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

thank you to colleagues Armstrong, for fighting me to speak this evening. My eye and salts are from a clinical lead on consultants in a D J J critical care unit and not seem sure on on. But I'd like to share just my observations, perhaps on also our experience with dealing with the uncertain, Um, I suspect says, managing patients in critical care in the context of coated so heart back to, um just every year ago in 2019, when we were all out having a good time. And this is picture of man of friends having pre Christmas meet up on on gilded. We know that this was probably getting to be Uh huh. Not a possibility going into the So our plans were fairly ambitious with your head. Will Have you seen the inspection coming in February? Planning for a new build on DCA mission ng for improved services on also increasing the amount of follow from rehab that wants to provide on on. But unfortunately, as as we expect or good plants, do you get a car pushed on? But we started seeing that reports coming in from Far East regarding this new on D virus, which WAAS was significant concern and it was being labeled is it is a sauce which immediately had a long bells for us in critical care, particularly around world on. And I think that was the key that people outside of critical carry a respiratory medicine didn't know really fully appreciate, particularly within the UK. The importance of this on the potential worries that we have on day. We're putting it down pretty locally to something that's going to stay in China, and it's not gonna come to us. So we were already having talks, perhaps local regionally, about the experience elsewhere, particularly during sauce in the mid two thousands in farming standard catheter on. We saw the actually reason a lot of treatment to these patients. It's not a curable sees per se, but this was the best that we had was observation alone data on outcomes from treatments. And they introduced particular and also that this was, um, showing perhaps spinal recent experience of the UK, so response to the trends a pandemics which also guided us how to treat perhaps viral and the viral responder a failure in the intensive care units. But there were lots of the nose on concerns regarding on a result, generating procedures and IV on also treatments that possibly wouldn't work. Not sure on also for me. Personally, I remember listening to fastest. You're from Toronto, speaking about their experience, which was extremely emotional, on highly relevant to where we're going. And I think that then as it stands, we have not prepared ourselves to this degree on. But it's courters unaware. But it has been. I don't think that the critical care community has stood up and shouted by this to ensure that we have tried a best to make the best response that we can safely as possible. So some things that we weren't really sure about was the's event on V. Perhaps on this was starting to be talked about or beginning to use this or not on. We knew that there was some data saying that use of an IV in severe er TX isn't necessarily great, but ball season because own fantastic. Um, but if an IV failure occurred in fourth Simpson of patients with severe ideas than it did and remained onda always are, we likely Oh, happy to accept those numbers. A zone outcome benefit with. So these are hospital on day, whilst it's all nice and shiny and new front. Unfortunately, we're sort of took away the back in the old build with agents stated infrastructure on were no older open by a unit with 30 bed spaces also, uh, severe changes with their changes Options supply, supply out services ultimately to affect deprived area Um, which has, um, a significant deprivation from, um from that after effects off the kind of the mining industry, but also on social aspects of obesity and mental health problems on our patient population are predominantly white British. So we start season parallels when these, um, these pictures started coming from Bergamo, a relatively younger people, um, lying up in CPAP wards. Be hasty made. We've started to get our non critical cameras. Brooky teams focus that this was attention coming to us, so we were starting to plan on. Do we advised Armstrong in tow, see if we could have some capacity to utilize more high flow devices if we were going to be going down the route of what was coming in in Italy, perhaps on. And then he starts to find out that actually um this Waas not necessarily going to be easy to do, given the fact that our oxygen flows the ward's was in the region of 50 to 60 fleas a minute, cardboard and and also that we were significantly limited by the amount of ventilation air changes within the new build as well. A Z on the unit itself, on advice came out saying that type of a nasal probably shouldn't be used and also that they use the CPAP should be confined to short periods on the significant risk of a GPS s. So that's sort of put a lot of this to bed straight away. So we heart back to effectively preparing ventilation. I see you use on. We have the capacity to ventilate 45 patients with day case. Recovery is well available, so we have ventilators. We had done a sense of machines, but everyone was ultimately either going to be on oxygen or going to be integrated. That wasn't going to be a necessarily a significant amount of capacity to offer I floor seat up on, then this came out a few weeks later, which identified, that's, um that actually, maybe we might be able to use a bit more CPAP perhaps, but by then, our infrastructure was, um, available to facilitate this. To this degree, we did have a whole number of CPAP cubes, which we're ready to be used if we were to get overwhelmed on. But we have these prepared curtsy respiratory teams on I'm ready to go. But reality for us was that we ventilated virtually all about Kobe pneumonias, and this was just one the 300 sheets that we had given day and off walls. Um, we were being with on. I think it's probably not particular different. Too many other patients in other units across the country's not the world on. By mid April, we could see the only a third of patients really were getting basically spiritually public in to what been said and from the initial advice on maybe over those that slightly better brand required. That's oxygen in the first place. But then we also have this and not sure, but everywhere utilized this even that these were the agreed numbers for escalation, that if we had gone down this route that we would been overwhelmed pretty much pretty quickly on we. We did go down the roots of having altered prime ministers. And our ballpark was the 30 60 90 which can was utilized by other units. A swell of a respiratory rate approaching 30 with an F i 02 of grace and 60. And so that's not managing 90 and for a respiratory and outreach colleagues to get us involved in once they get into that stage, despite medical management on the boards, we would take dance in intensive care with View Teo either possibly thinking about CPAP in the first instance, but actually going on being intubated fairly quickly. And we were Maurine kind with this source of model, perhaps using a a low option target. Then the mid nineties on, be utilizing away pronating on the unit, which still haven't really got to the degree that you like to have done across the ward's on. Our outcomes were quite good over all of the 35 patients that can't assume your interest rated by died, but the other survived. But we we do say that the Apache school, perhaps that a lot of these people, um, I would have probably done well with with, um, see how alone we noticed that our athletic machines were constituted a significant risk on that. Actually, we need to bronchoscope patients. We just did it. Unification, Ulcer, hatred. Knees were not good on. We quickly moved over to use a heating. Unifies all of them. I'm accepting the risk that we were in comported convert areas. Option flares, we say, was a finish on the boards. And that was significant concern regarding contamination. Use of a GPS on our search. People found safe when patients were intubated. So we went into September. Andi Oxygen option promises were reduced, perhaps on the nose for us. We haven't used a lot cpap before. On this time there was failure to respond. Lower requirements look comfortable. It was all very subjective and nothing really. Your hair on should be keeping people on CPAP fall. Perhaps. And then we started to see this That more more patients where coming through. But having defined heart borders on the X rays on, then we're getting them through a CT scan once they're integrating potentially or on the way down from the wards and find that they have the mediastinum, which we didn't see a lot of at all. First time around eso again The questions for me. Really? What do we use? What should be using? How long should we use it for? And it's still, you know, if only we all say this that if the recovery are rested, did just, um, was able Teo you to buy some of the time on CPAP price of education. That would be helpful. Hopefully that will be it. Secondary analysis may be helpful for us going forward. And so the HMO groups were noticing this is well, the patient was stuck on an IV for a lot longer on. Then they started to utilize a CPAP. An IV use is part of ventilated dates because they release the statements on saying that. Actually they we're seeing poor outcomes in those that had been on CPAP for a lot longer on may be that these patients being delayed to be intubated was leading to poor outcomes. Elect And then we have the BTS ICS guidance as well, which I think unfortunately, it's I find that it was we had a similar discussion about this without spirit, your colleagues, but it doesn't keep in is not in keeping with recovery. Artist trial of comparing oxygen versus see versus flu on As a consequence, we hope that this will be changed pending the outcomes off. Because we are rest trials, Um, which is to say, compares to three Sundays. So in January in the BMJ, there was this editorial which looked at what the Atkins were for that patients compared to the first wave until mid summer, last year, too, the end of 2020 on similar numbers but clearly a long walk. A number of patients being having basically spiritually support alone, um, on less people being ventilated also any stage. But we are mindful to see what actually happens. The outcome data once these are receiving care, um are completing the critical care of hospital stays. So the owner is the main really, are what's happening prior to them coming into the hospital on down Also, what's happening on the ward prior to escalated option therapies have itself running. Are they getting on then for us sitting with a patient SATs of the high eighties low nineties on CPAP but looking relatively comfortable, um, on their phones, two days on end, how long would we hold out for but also knowing that Our older patients are certainly not doing well at all once they are interested. If each basement full on and also the evidence that's been a master is, is piecemeal. The different observations studies that looked at use and different senses that used different agents. Many hospitals using fossil use a mouse in the first wave on day steroids. With me, I'll pred a lot, lot higher doses, perhaps eso their data. And there are times perhaps or not was comparable. As with what we did first time around, maybe going forward with the outcomes of the various trials and Madonna's He's been in a better place. So I looked at some of these papers, which I think just the conversation. I'm not an academic. This is just me is a job in intensive. It's looking at the painters that here on be the first ones from who's group in um on. Their key thing was that they showed that using high flow alone in that patients who were relatively well on through the first wave and hard 60% of people did well on my flow alone didn't require a situation beyond that on do you till I lock store at six hours a zoo A as a marker of how well they're potentially going to do on. And then this was categories group from South Africa on again. Similarly, half the patients there did well on high flow alone again with significantly severe peer fresh shows. Um, I get and they also utilized rock scores on their box scores a city street 0.7 a z a positive predictor. Um, interested in the mortality of those felt was very high. Candles group in the States again looked at a numbers and they they had a success of 60% of people weaned off high flow. But again, they also received my failure rates more with mortalities, um, in this group. And so this paper was from Theophylline group and they looked at their patient. Fasting numbers will lower the This is the first thing where I started to see the the actually use of away pronating being so significant and actually how important it waas to utilize the bundle of care of not just the CPAP game and promethazine. Well, perhaps, and they have a zone independent predict of mortality on It's so difficult often times with the patient groups that we have who have either a b c a little bit older. I've got the issues of the discomfort of being on that front, um, or the physicality of being a particularly those high. But how important it really is to push that on. So this is the normal arms group in South Bend in England on. They had a really good algorithm. I thought for this where they also showed that a good number of fair 40% avoided intubation who had seen up alone. And I think they followed a very similar type of, um uh, guidance that many of the units that have used perhaps, But maybe the utilizing of this level of saturation is probably not the same as many of the units locally. We certainly did not use SATs. And 94 is our marker of interest rate of them. And we sat with lower starts with those particular nights 2 93%. And but also other subjected measures on. This was also one of the unknowns that said that actually, one c was initiated within four days. The hospital admission they did all right, if they're out. Oh, this was from a she she grew up in. William is looked around 200 patients. A retrospective they used to sleep up near cute shoes, which we found, um, a very a ble in usage. Perhaps on that the fire team was not necessarily quantifiable. We piped intensive 15 leagues. Oxygen gave Nephi to possibly between 50 and 70 to 80% at times. But as we say, I think that the issue of actually, um utilizing CPAP within a short friend of time was was associating with a better outcome. This was again a group from From livable on. They saw that again half their patients avoided intubation on their outcomes were fairly good in those that were four escalation. Um, I meant this is a a a fair, poignant paper as well To highlight whether or not we would implement CPAP for patients who would be would not be for escalation on. They saw that those that had seat up a seeing of treatment that the mortality was extremely high. Um, but actually again, they were able Teo, avoid interpretation in a significant number. So what now? For us is waiting for 30 60 92 late, perhaps on should we be doing something a bit sooner? I think that's reflected in the and because of the trial of getting people in, you've got. And if I had to requirement great and 40% I'm not. Managing SATs of the low to mid nineties clinical discretion is a big confounder in all of these that when his decision to intubate I'm were wet with anticipated breath, the outcomes of the country trial on the secondary analysis on you. Also, we hope that the beach yes, I see it's guidance and is reflective of what just said prior to this on utilizing on CPAP early on. I see that's what we've been doing now on using high flow, just a facilitator eating, drinking and also how utilize our observation allow. It comes in the context of dexamethasone. Possible is, um, um, intermediate dose England little away heparin's keep him a bit more wet, perhaps because they've not been able to drink, perhaps well, awards or prior to coming in and also protein. And then again, I totally, pragmatically maybe it seems I'm looking at all the papers from just for other people are doing, perhaps to intubate. By Day five if they're looking worse. But we can't go away from the fact that, actually the outcomes for our older patients is pretty poor on. I think we do need to enter into a conversation on early with patients and their relatives is the likely outcomes up? But I'm still finding extremely difficult, not, um, offer it in those that are fit healthy but over the age of 70 on diet still currently offering that and in lights off and what we would do for patients who are critical, spiritually failure and thank you very much.