Comprehensive summary

#ISICEM-BRACE Meeting: Brain Critical Care and Emergencies.

In this opportunity, we heard from world-wide experts the latest concepts on neurocritical care management. Faculty members included a multi-disciplinary team conformed by intensivists and neurologists. Key topics on the management of several acute neurological emergencies were discussed. Here, a brief summary of the highlights from the BRACE meeting.

Cerebral blood flow and oxygenation 
Mauro ODDO (Lausanne, Switzerland)

"The most important aspect is the balance between flow and CMRO2".

Vasospasm is a multifactorial event that involves the dysfunction of molecular pathways activated during the acute phase. Dysfunctional pathways included the nitric oxide pathway (impaired blood flow stability) and prostacyclin (impaired vasodilation). Other abnormalities include microvascular dysfunction,  micro-thrombotic vascular occlusions and cortical spreading depolarizations.

Is cerebral micro dialysis helpful?
Raimund HELBOK (Innsbruck, Austria)
"The primary objective after brain injury is the prevent secondary insults".

Cerebral micro dialysis (MD) is still considered an experimental technique and no guidelines are available to use MD in clinical practice. However, it is becoming more evident that regional monitoring of cerebral tissue may be associated with better outcomes. Indeed, PbO2 may not detect as many as 50% of ischemic episodes.

How systemic hemodynamic influence brain function?

Daniel deBacker (Brussels, Belgium)
"The alteration of brain microcirculation during sepsis affects cerebral blood flow"

During sepsis, leucocyte and platelets adhesion the endothelia induce brain microcirculatory dysfunction. These microcirculatory derangements lead to cerebral blood flow alteration and reduction on tissue oxygen tension (PbO2).

Anemia and RBC transfusion
Fabio Taccone (Brussels, Belgium)
"How low can you go?"

The decision to transfuse is related to the severity of the disease. Anemia is associated with poor outcome if associated with low PbO2. RBCT may improve tissue and brain tissue oxygenation. However, liberal RBCT strategy is associated with increase rate of secondary complications such as ARDS, infectious, and microcirculatory alterations.

Fever control
Paul Vespa (LA,USA)
"The brain is 1 degree warmer than the rest of the body"
Fever is very common among patients with brain injuries. Fever is associated with worsening neurological outcome. However, fever can be effectively controlled and intravascular cooling devices seem to be better than surface cooling devices.

ICP crisis
Nino Stocchetti (Milan, Italy)
"What matters is the consequence of increase ICP and not the actual number"

If ICP increases from 8 to 18 but with associated reduce awareness, mydriasis or hemiparesis then treatment must be initiated immediately. However, if transient increase in ICP is not associated with any neurological signs, than immediate treatment is probably not necessary. 








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Comprehensive summary

#ISICEM-Course on Metabolic and Nutritional Issues 

in the ICU.

Day1

Today was the first day of the advance metabolic and nutritional ICU course, were world-wide experts debated on critical issues of daily ICU management. Authors come from different countries such as Belgium, France, Sweden, Netherlands, Germany and Switzerland.
Here we present a comprehensive summary of todays key messages from each speaker.




Metabolic response to stress. 
Dr. Jean-Charles Preiser (Brussels, Belgium)
"Homeostasis is needed for life"
During critical illness, circulating levels of orixigenic hormones (gherlin), are reduced. Also,  circulating levels of anorexigenic levels (PYY), are elevated.

The benefits and risks of insulin resistance.
Dr. Peter Soeter (Maastricht, Netherlands)
"The brain does not rely exclusively on glucose"
In critically ill patients, a target blood blood glucose level of 10 mmol (180 mg/dL). Lower levels increase the risk of hypoglycemia and decreases the host response to injury. With 50% of energy requirements covered by glucose, this risk is diminished in host response promoted.

Protein catabolism.
Dr. Jan Wernerman (Stockholm, Sweden).
" Techniques to asses protein metabolism have inherent limitations".
During critical illness, protein catabolism is unevenly distributed in between organs. This means that protein stores  could not be use to maintain homeostasis. However, measurement of proteins metabolism during critical illness is related to measurement biases.











Anabolic resistance
Dr. Jean-Paul Thissen (Brussels, Belgium)
"We should try to increase anabolic stimulus and decrease the resistance threshold"
Anabolic resistance was defined as the inability of skeletal muscle to respond to anabolic stimuli by stimulating protein synthesis and inhibiting proteolysis. There are several factors associated with increase  anabolic resistance such as age, inflammation, cancer, splachnic sequestration and micro-vascular alterations.

Autophagy
Dr. Michael Casaer ( Leuven, Belgium)
" Suppression of Autophagy was associated with organ failure"
Unfortunately, results from a animal studies depicting the role of autophagy have been un-conclusive. More data is needed to understand the role of this highly preserved pathway during critical illness.

Gastrointestinal dysfunction
Alain-Michel Dive (Yvoir, Belgium)
"Patients in the ICU have abnormal inter digestive migratory motor complex function and are not able to start a normal feeding pattern".
Patients that are mechanically ventilated have abnormal retrograde duodenal bolus propagation with almost zero activity at the gastric level. This increase the risk of ileus and broncho-inhalation.

Management of gastric residual volumes
Dr. Jean Reignier (La Roche Sur Yon, France)
"The myth of gastric volume"
Gastric residual volume monitoring should be removed from the standard of care of critically ill patients receiving mechanical ventilation and early enteral nutrition.

Measurements of energy expenditure
Dr. Elisabth de Waele (Brussels, Belgium)
Formulas for estimating the caloric need of critically ill patients are not reliable. Theses formulas may over-estimate the caloric need and thus increase the risk of over-feeding.
However, indirect calorimetry can be performed in only 50% of patients in the ICU, and technical issues make this technique also difficult to perform.

Protein turn-over
Dr. Jan Wernerman (Stockholm, Sweeden)
" The use of protein turnover measurements has the potential to guide protein feeding to critically ill patients"

Assessment of body composition
Dr. Claude Pichard (Geneva, Switzerland)
"It is almost impossible to measure body composition in ICU patients".
Assessment of body composition by CT-scan or MRI could correlate with nutritional risk and outcome. It could reflect the efficiency of nutrition support and thus allow to tailor treatment to patient´s characteristics.








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