The Critical Care Commute Podcast

In this episode, we welcome Professor Mervyn Singer, author of Sepsis 3.0. Sepsis remains one of the most complex and deadly conditions in critical care. In this conversation,Professor Singer shares his perspectives on the shifting landscape of sepsis treatment, the role of antibiotics, steroids, metabolic interventions, and the future ofprecision medicine. He also challenges some long-standing dogmas and emphasizes the importance of individualized care over rigid guidelines.Key Topics and Chapters:The Evolution of Sepsis ManagementHistorical perspectives on sepsis treatmentEarlier recognition and intervention leading to improved outcomesCurrent Challenges and Research DirectionsOrgan dysfunction and recovery in sepsisThe importance of metabolic manipulation and mitochondrial functionThe Role of the Immune System in SepsisUnderstanding hyper- and hypo-inflammatory responsesSteroid use in critical illness—when it works and when it doesn’tAntibiotics in Sepsis: How Soon, How Long, and How Much?The changing approach to antibiotic timing and durationThe impact of microbiome disruption and antibiotic toxicityRethinking the one-hour antibiotic ruleLessons from COVID-19 and Their Impact on Sepsis ResearchThe importance of phenotype-driven treatmentsMissed opportunities in clinical trials and biobankingThe Beta-Blocker Debate in SepsisPotential benefits in selected patientsThe challenge of distinguishing compensatory tachycardia from harmful sympathetic overdriveRethinking Fever ManagementIs fever protective or harmful?When to treat and when to leave it aloneGuidelines vs. Individualized CareThe balance between evidence-based medicine and clinical expertiseThe dangers of rigid mandates and protocolsThis engaging discussion provides a fresh perspective on the current state and future of sepsis management, emphasizing the need for precision medicine, nuanced clinical decision-making, and ongoing research.References:Im Y, Kang D, Ko RE, et al. Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study. Crit Care. 2022;26(1):19. Published 2022 Jan 13. doi:10.1186/s13054-021-03883-0 HereSakkat A, Alquraini M, Aljazeeri J, Farooqi MAM, Alshamsi F, Alhazzani W. Temperature control in critically ill patients with fever: A meta-analysis of randomized controlled trials. J Crit Care. 2021;61:89-95. doi:10.1016/j.jcrc.2020.10.016 HereHasegawa D, Sato R, Prasitlumkum N, et al. Effect of Ultrashort-Acting β-Blockers on Mortality in Patients With Sepsis With Persistent Tachycardia Despite Initial Resuscitation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Chest. 2021;159(6):2289-2300. doi:10.1016/j.chest.2021.01.009 Here

Dr. Shannon Fernando is an intensivist at Lakeridge Health and a prolific researcher with over 150 publications. Known for his work in outcomes-based research across critical care, he joins us to discuss long-term outcomes after cardiogenic shock.About the Episode:This episode is part of our cardiovascular critical care series and explores what happens after the ICU for patients who survive cardiogenic shock. We unpack quality of life, functional outcomes, mental health, and the hidden burdens on both patients and caregivers. Dr. Fernando provides key data insights from his large cohort studies and shares reflections from ICU follow-up clinics. We also dive into the challenges of prognostication and how to communicate realistic expectations to families.Topics CoveredDefining Long-Term Outcomes:Beyond survival: functional independence, mental health, cognition, and system resource use.Key Findings from Ontario Cohort42% of cardiogenic shock survivors require increased levels of care15% die within a year post-dischargeModest impact of revascularization or mechanical support on long-term outcomesMorbidity and Quality of LifeLoss of independence and inability to return to workHigh incidence of PTSD, depression, and caregiver burdenDelayed functional recovery and unmet expectationsPrognostic Factors and Predictive MarkersFrailty as a key indicatorPre-existing mental health as a predictor of post-ICU mental health outcomesIn-hospital arrest characteristics: rhythm, downtime, comorbiditiesICU Follow-Up ClinicsValue in knowledge translation and emotional supportReal-world insights on functional recovery and patient satisfactionCommon patient sentiment: gratitude mixed with traumaCommunication with FamiliesAvoiding value impositionEmphasizing trajectory over fixed timelinesBalancing hope with realismRethinking Endpoints in ResearchLimitations of 28-day mortalityNeed for patient-centered, long-term functional outcomesTrajectory-based data over snapshot metricsKnowledge Translation as the InterventionEquipping clinicians and patients with realistic expectationsNormalizing psychological responsesShaping future research directions around lived experience

Dr. Emilie Belley-Côté, an Associate Professor at McMaster and expert in critical care cardiology, dives into the complexities of cardiogenic shock and the SCAI classification. She breaks down the five stages, illustrating their significance for patient care and interdisciplinary communication. The conversation highlights the critical need to recognize pre-shock conditions and the real-world applications of SCAI in guiding treatment decisions. Dr. Belley-Côté also touches on the challenges posed by mixed shock and the latest advancements in cardiac monitoring.

Dr. James Downar, a leading Canadian expert in palliative and critical care, dives into the fascinating world of psychedelics and their potential to alleviate psychological distress in patients facing critical illness. He discusses the transformative powers of substances like psilocybin and MDMA, exploring how they can help individuals confront fear and isolation. The conversation covers the structure of psychedelic-assisted therapy, the importance of 'set and setting,' and the need for compassion in integrating these therapies into traditional care.

Prof. Mervyn Singer, an ICU physician and critical care thought leader, shares insights on ischemia-reperfusion syndrome, a paradox where restoring blood flow can worsen injury. He breaks down the complex mechanisms at play, such as mitochondrial involvement and oxidative stress. The conversation delves into the variability in physiological responses to stress, advocating for a tailored approach to ICU interventions. Prof. Singer emphasizes the importance of clinical judgment and flexibility in treatment protocols, aiming for patient-centered care.

Dr. Mike Christian, a specialist in pre-hospital and critical care medicine with a military background, shares valuable insights on transforming emergency services in Canada. He discusses his unconventional journey from paramedic to physician, highlights the integration of AI in emergency dispatch, and contrasts Canada’s pre-hospital care with global models like the UK's. Mike emphasizes the critical role of physician-led teams, mentorship, and emerging technologies in improving patient outcomes and survival rates during emergencies.

Dr. Elizabeth Viglianti, an assistant professor and critical care specialist at the University of Michigan, shares her expertise on gender-based harassment in the medical field. She recounts her personal experiences that fueled her passion for this vital topic. The conversation delves into the prevalence of harassment and its impact on professional dignity, especially for women. Dr. Viglianti discusses systemic barriers in reporting and highlights recommendations for creating a more equitable and supportive environment in medicine.

We take another break as we are joined by Prof. Wendy Sligl, formidable ID and ICU doc, to discuss the critical topic of optimizing antibiotic prescribing in critical care settings. The discussion covers various aspects of antibiotic use, including the importance of timely administration, the role of communication in ensuring effective treatment, and the nuances of dosing strategies such as loading doses and continuous infusions. The conversation also delves into the duration of antibiotic therapy, emphasizing the need for individualized treatment based on patient response. Takeaways:Infections are common in intensive care units, and sepsis is a life-threatening condition.Identifying the clinical syndrome is crucial for appropriate antibiotic therapy.Empiric therapy is often necessary before culture data is available.Timely administration of antibiotics is linked to better patient outcomes.Communication among healthcare teams is essential for effective antibiotic delivery.Loading doses can help achieve therapeutic levels quickly in critically ill patients.Continuous infusions of certain antibiotics may improve clinical outcomes.Shorter courses of antibiotics can be as effective as longer ones.Monitoring patient response is key to adjusting antibiotic therapy.Consulting infectious disease specialists can enhance treatment strategies.Chapters:00:00Introduction to Antibiotic Optimization01:07Understanding Infections and Sepsis02:47Emergency Room Protocols for Antibiotic Administration04:56Identifying Sepsis and Administering Antibiotics06:33Communication and Timeliness in Antibiotic Delivery08:42Optimizing Antibiotic Dosing Strategies10:59Pharmacodynamics and Continuous Infusions12:44Duration of Antibiotic Therapy18:52Monitoring and Adjusting Antibiotic Treatment21:39The Debate on Antibiotic Duration26:37Specific Infections and Treatment Duration31:24Practical Strategies for Antibiotic Stewardship32:43Rapid Fire Questions on Antibiotic Use

Dr. Darryl Abrams, Associate Medical Director of the Medical ECMO Program at New York-Presbyterian/Columbia University, dives into the transformative world of extracorporeal cardiopulmonary resuscitation (eCPR). He breaks down key trials like ARREST and Prague OHCA, highlighting their impact on clinical practice. The discussion covers challenges in implementing eCPR, including patient selection and ethical considerations regarding access to this advanced care. Abrams also contrasts healthcare models in the U.S. and Canada, shedding light on disparities in treatment.

Dr. Sean van Diepen, an Associate Professor and Co-Director at the Mazankowski Alberta Heart Institute, shares his expertise on extracorporeal life support in cardiogenic shock. He discusses the evolution of mechanical circulatory support, highlighting findings from the DANGER trial showing a 20% mortality reduction with the Impella device. The ECLS-SHOCK trial raises concerns about complications despite lack of mortality benefit. Van Diepen emphasizes the need for better patient selection and collaborative care in this critical area of cardiac medicine.