Coda Change

From CodaZero Live, Steve Morgan talks to us about temporary mechanical circulatory support in cardiogenic shock. Steve gives an example of a patient with refractory cardiogenic shock, who hasn’t responded to pharmacological support. So, how do we go about choosing between temporary circulatory support options? First, Steve acknowledges that critical care echocardiography is central. Additionally, he discusses the use of pulmonary artery catheters.  Finally, Steve hopes that future Randomised Control Trials might contribute to a better evidence base to guide the use of these supports in specific patients. Finally, for more, head to our podcast page #CodaPodcast 

Brain injury outcomes and predictors by Kiran Lele Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources. However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task. Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome. Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models. There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases. We end with three brief vignettes which highlight the fraught nature of long term outcome prediction. For more head to, https://codachange.org/podcasts/ 

In this podcast, Celia Bradford talks to Bing Brotohusodo about a challenging time in his life. Early in 2020, Bing contracted COVID-19. This resulted in a two-month hospital stay and admission to the ICU. Celia was one of Bing's physicians and together, they reflect on Bing's time in hospital and his recovery. Bing was as a helpful patient. So much so, that he was able to prone himself! However, Celia recalls how challenging it was treating Covid in those early days. Staff were desperately trying to work out what Covid was and how best to treat it. The question of "are we doing the right thing?" was always in the back of people's minds. Furthermore, this was exacerbated by the confusion of multiple treatments being promoted in the media. There were countless opinions about how Covid should be treated. Information was flowing fast, making it challenging to discern what the best way forward was. Celia and Bing reflect on Bing's time in ICU and his post-COVID recovery. Tune in to a podcast from #CodaZero Live on a patient's perspective of COVID-19. For more head to https://codachange.org/podcasts/ 

In this second episode on vascular access, the team from the Australian Vascular Access Society (AVAS) discuss vessel assessment with RaCeVa and RaPeVa as well as the use of Micropuncture and establishing optimal catheter tip position.  Before puncturing a vessel for vascular access it is important to: Trace the anatomy of the vascular pathway for aberrancy Ensure that the vessel calibre is suitable for the chosen catheter Ensure no obstruction with thrombus or occlusion Moreover, it is vital that the catheter doesn't occupy more than one-third of the diameter of the vessel. This will significantly reduce venous blood flow and increase the risk of catheter-related thrombosis. For PICC line insertion the arm can be divided into three zones to select an optimal vessel puncture site. The brachial fossa region is a "Red - no Go" zone, the mid-arm is the "Green - Optimal" zone and the proximal third of the arm is a "Yellow - Axillary" zone. When inserting a line, the catheter tip should be at the cavoatrial junction approximately 3-5cm below the carina on a chest X-ray. The use of a navigation system like catheter tip ECG (intracavitary ECG) is extremely accurate. It is often still useful in patients in atrial fibrillation but more difficult for patients' with paced rhythms. For more like this, head to codachange.org/podcasts/ 

The prehospital management of patients with moderate and severe TBI can be complex.  In this podcast, Marty Nichols talks us through managing patients with TBI in a prehospital environment. This involves avoiding hypoxia and hypotension, ensuring a safe transportation and getting to the right treatment centre the first time.  Notably, due to the nature of the accident, patients with a severe head injury also often present with other injuries. Managing multiple injuries at the same time has implications for how TBI's are managed and treated in prehospital settings. First and foremost, clinician's should prioritise the prevention of hypoxia and hypotension when managing TBI patients. This includes effective airway management, however, airway management and the prevention of hypotension present some of the greatest challenges to clinicians.  Marty discusses the challenges in treating patients with TBI in prehospital environments. Furthermore, he discusses the processes in place which help to ensure that these patients have the best possible outcomes.  For more head to https://codachange.org/podcasts/ 

In this podcast, Ed Litton summarises 10 clinical trials in 10 minutes. Ed invites you to choose, based on the title alone, whether the findings were consistent with, or contrary to, the study hypothesis. Ed discusses 10 non-covid clinical trials, all published in 2020. Notably, all of these were published in the New England Journal, JAMA or Lancet and had important findings. The following hypothesises are discussed: 10. Firstly, the impact of resident physician schedules and the affect on patient safety. 9. Early initiation of renal replacement therapy and whether this improved outcomes for Acute Kidney Injury. 8. Does the implementation of early ECMO improve outcomes for patients with refractory VF and out of hospital cardiac arrest? 7. Then, can a machine learning algorithm reduce hypotensive severity? 6. In mechanically ventilated patients, is an approach of non sedation superior to light sedation? 5. Moreover, in patients who are ready for decannulation, does timing based on the suctioning frequency improve outcomes? 4. Does administering high dose tranexamic acid in patients with upper or lower GI bleeds decrease mortality? 3. Next, does a decreased exposure to vasopressors improve outcomes in older critically ill patients? 2. Will starting Dexmedetomidine at the time of cardiac surgery reduce AF and delirium in patients? 1. Also, will being conservative with oxygen in patients with ARDS improve outcomes? Tune in to a talk by Ed Litton as he shares the top 10 papers of 2020 in 10 minutes. Finally, for more podcasts head to https://codachange.org/podcasts/ 

In this podcast, Claire discusses the role of clinician communication and its impact on acute pain management. Claire explains how pain management outcomes can be optimised by enhancing patient expectations of benefit via patient-provider communication. Firstly, what we say to patients matters. Secondly, how we say it also matters. Pain is a complex phenomenon and managing expectations of pain and people’s experience of empathy is crucial. As healthcare professionals, we see multiple patients and are often run off our feet, but, as the studies clearly demonstrate… communication matters. And it matters a lot in pain management. This presentation shares research demonstrating the impact of clinician communication. Specifically, this includes how clinicians' talk about pain and pain management. Claire discusses the importance of patients' experience of pain, the effectiveness of pain management and patients' treatment outcomes. From CodaZero Live, tune in to a fascinating discussion on the importance of communication.  For more like this, head to https://codachange.org/podcasts/ 

From CodaZero Live, Alex Rowell reviews the available advanced liver supports for patients with acute liver failure. Artificial supports for the liver are quite complex and difficult. This is largely due to the liver's complex function. Some of the advanced liver supports include CVVHDF, Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and high volume plasma exchange. In this podcast, Alex takes us through the research and evidence for these supports and shares some guidance on when they should be used.  CVVHDF is familiar and effective but we need to remember to use it early with acute liver failure patients. Furthermore, Molecular Adsorbent Recirculating System (MARS) is widely studied but unfortunately not available in all places. Single Pass Albumin Dialysis (SPAD) is easily implemented. Although there is less evidence on SPAD, it is generally agreed to be an effective support. Unfortunately, there are no mortality benefits in any of these supports. They are however, useful tools in bridging to transplant. For more head to https://codachange.org/podcasts/ 

In this podcast, Ruth provides a summary of surgical considerations when managing an injured spine patient. She covers imaging considerations, indications for surgery and challenges to delivering excellent surgical care.   Ruth shares a story of one of the most severely injured patients she has ever looked after. A 78 year old woman came into a trauma centre having been driven over by a 4WD... twice.   She had a fractured lower limb, significant chest trauma, a significantly deformed torso, she could not feel or move her legs (other than wiggle her toes slightly) and she had tyre marks on her torso...    When looking at her injuries, it was clear that she had a significant group of chest injuries. This is an important reminder that spine trauma happens in the context of multi trauma. This subsequently impacts every step of the care process including surgical planning and management.    The objective from the outset is to try and get patients like this to theatre as quickly as possible but there are surgical considerations to take in to account.    Tune in to an incredible story as Ruth shares that the key to success is simple things done well, done consistently and in a team environment.  For more head to  https://codachange.org/podcasts/ 

Chris provides a brief update on some of the postulated underlying mechanisms involved in subarachnoid haemorrhage associated brain injury. These mechanisms provide hints to future therapeutic targets that will hopefully expand our currently limited repertoire of options. Subarachnoid haemorrhage is a catastrophic type of stroke. Subarachnoid haemorrhage represents only 5% of the total stroke burden. Notably however, as it is most common in people aged 40-60 years, it has a disproportionate effect from a personal, social and economic perspective. Subarachnoid haemorrhage classically presents as a thunder clap headache and loss of consciousness. Unfortunately, it is associated with high morbidity and mortality rates. There is limited research in this area and there is significant opportunity to improve the way that we manage these cases.  The key is understanding the link between early brain injury and why we develop delayed cerebral ischemia. How can we stop this from happening? How can we better understand why good brains go bad? From #CodaZero Live, Christopher Andersen provides an update on delayed cerebral ischaemia. Join Chris as he looks for future treatment options through the mechanism of brain injury in subarachnoid haemorrhage. For more like this, head to our podcast page. #CodaPodcast