The 12th annual ASCCA meeting was attended by approximately 160 people who heard ten slide presentations, lectures by a distinguished lecturer, a young investigator, and the ASA president-elect, as well as an afternoon plenary session on state-of-the-art care of the patient with acute respiratory distress syndrome (ARDS). The oral presentations and eleven additional posters were published as a supplement to the September issue of Anesthesiology. These presentations addressed topics ranging from amino acid substrate effect on CNS autoregulation to gene expression in sepsis to modes of NO delivery to adenosine A1 receptor modulation in renal ischemia (the subject of Dr. H. Thomas Lee's young investigator talk).
Dr. Richard Teplick, of Brigham and Women's Hospital in Boston, was the ASCCA distinguished lecturer. He lectured on "Using Basic Concepts to Assess Complex Problems: Applications in Critical Care Practice." He reminded the audience that in this era of algorithm- and critical pathway-based medical practice, we need to return to the basic principles upon which we were trained. He implored us to evaluate the quality of data we receive in the ICU, question the data if they do not make sense, and not hesitate to revisit the scientific principles upon which such data is developed and acquired. He supplied examples such as PAC use and wedge measurement, multiple inert gas analysis, the concept of work of breathing, and the administration of renal dose dopamine as ongoing clinical controversies. He advised clinicians to maintain their clinical skills based on a solid scientific foundation, not reflexive policy.
Dr. Ron Mackenzie discussed various topics of interest to intensivists and generalists, including comments on the recent ASA/ASCCA liaison on critical care practice and the future of critical care training during residency. Dr. Mackenzie has established an annual interaction between ASA leadership and the seven or so subspecialty societies to facilitate communication and mutual support. This initiative will aid in committee appointments, governmental affairs activities, reimbursement issues and interactions with acute care practitioner groups.
The plenary review of ARDS started with an insightful overview of gene therapy techniques in ARDS by Dr. Cliff Deutschmann from the University of Pennsylvania. He discussed techniques using adenoviral-mediated gene vectors and described preliminary work in animals that evaluated modulation of gene expression and protein synthesis. The ultimate utility of this remains open to debate at this stage.
Dr. Brian Kavanagh from the University of Toronto then succinctly
discussed the role of ventilatory strategies and their effect on outcome in
ARDS patients. He started with a brief comment on the "high-stretch/low-stretch
debate" recently reviewed in the October edition of AnesthesiaWeb (see "Mechanical
Ventilation in ARDS". This NIH-sponsored work shows that outcome is improved
by low tidal volume ventilation. He went on to discuss the effect of ventilation
on cytokine production and modulation, the protective effect in animals of
hypercapnic acidosis, and the role of systemic translocation of bacteria through
the lung. This lecture was complemented by the fine clinically-directed refresher
course (lecture #271) by Dr. Avery Tung on "Perioperative Management of the
Patient With ARDS."
Dr. Ron Pearl, recently named Professor and Chair of Anesthesiology at Stanford University, then closed the ARDS review with an overview of the checkered history and future of mediator modulation (anti-LPS, TNF, receptor manipulation) and inhaled NO, among others, as adjunctive therapy for ARDS patients.
A wide range of refresher course lectures (available in the classic ASA Refresher Course text or CD-ROM format) addressed critical care and perioperative issues. Among these were up-to-date reviews on "Management of Head Injury" (lecture # 133) by Dr. John Drummond, "Current Concepts in CPR" (lecture # 211) by Dr. Charles Otto, "Current and Evolving Issues in Transfusion Therapy" by Dr. Charles Despotis (lecture # 162, see subsequent transfusion committee report below), "Perioperative Hypertension: Evaluation and Management" (lecture # 154) by Dr. Mike Murray, and "New Cardiotonic Drugs" (lecture # 236) by Dr. Roberta Hines.
Dr. Drummond presented a practical approach to clinically relevant and controversial issues (C02 management, choice of fluids) in neuro-critical care interlaced with review of innovative therapies (jugular venous saturation monitoring, induced hypothermia, and discussion of unsuccessful recent trials with NMDA receptor antagonists and free radical scavengers). He focused on priorities in airway evaluation and management, cervical spine care, ICP monitoring, and treatment of intracranial and systemic hypertension, and fluid resuscitation.
Dr. Otto continues in his role as the liaison for ASA to the American Heart Association (AHA). He reported that updated CPR and pediatric CPR guidelines are undergoing final revision by the Board of the AHA. His lecture focused on ways to alter factors related to poor outcome during CPR: 1) long arrest time, 2) prolonged untreated v. fib, 3) and inadequate coronary and cerebral perfusion during cardiac massage.
Dr. Murray commented on the increased morbidity and mortality in the perioperative period in hypertensive patients. He reminded practitioners that hypertension is frequently under-treated and reviewed the AHA recommendations on blood pressure control and postoperative follow-up of patients with perioperative hypertension. He closed with a timely discussion on therapy of pregnancy-induced hypertension.
Dr. Hines reviewed recent data on the controversial topic of supranormal D02 in perioperative patients, use of dopexamine [a synthetic dopamine-1 (DA-1) and beta-2 agonist used in Europe], and the DA-1 agonist, fenoldopam, in her lecture on cardiotonic drugs. Her group also presented their experience with fenoldopam in CABG patients considered to be at high risk for postoperative renal insufficiency (creatinine > 1.4 mg/dL, IDDM, CHF, or prior CABG) (see Garwood, et al. Anesthesiology. 1999; 91:3A-154). In a small study of 59 patients there was a decreased incidence of postoperative renal insufficiency (creatinine > 2.0mg/dL) from ~19% in historic controls to 6.8% in those receiving low dose fenoldopam (0.03mcg/kg/min) (see Ann Intern Med 1998;128:194).
In addition to Garwood et al, ninety-one other critical care abstracts, along with CCM related topics in clinical circulation and respiration, were presented as posters or poster discussions. Drs. Murray and Teplick chaired a session on sepsis and trauma that focused on the molecular machinery, such as NF kappa-B gene encoding and synthesis and release of TNF, interleukins, and gamma interferon, felt to be responsible for development of the systemic inflammatory response.
Dr. David Warner of the Mayo Clinic and Dr. Roger Johns of Johns Hopkins, chaired the 1999 Anesthesiology symposium on "New Concepts in Lung Injury and Repair in the Critically Ill." The journal-sponsored symposium opened with two lectures. The first by Michael Matthay, MD, of UCSF revolved around mechanisms of acute lung injury. Professor Matthay discussed the concepts of volotrauma and barotrauma. Rather than taking a dogmatic approach, he outlined how each may contribute to ALI and ARDS along a continuum of disease pathology. While his obvious bias is in the volotrauma camp, he strongly supported control of airway pressures and, in particular, plateau pressure as a therapeutic intervention.
The second lecture was by Polly Parsons, MD, of the University of Colorado. Dr. Parsons, a pulmonologist like Dr. Matthay, discussed therapeutic interventions and supportive care in ARDS. Despite the failure of numerous "silver bullets", i.e., ibuprofen, ketoconazole, she noted the overall mortality for ARDS has decreased over the past three decades and attributed this to general improvements in care of the critically ill. The symposium concluded with a dozen presentations of original research in the field of ARDS.
There were also programs on adjunctive therapy in the perioperative period. Spirituality, herbal therapy (e.g., borrage seed oil in ARDS), the importance of sleep, palliative care, and advanced directives were discussed in this session. Some interesting take-away points in the spirituality lecture were that a large number of patients believe in the healing power of prayer (90% of surveyed patients) while 80% of those surveyed would appreciate physician inquiry into whether the patient's spiritual needs are being met.
Dr. Carl Hug, Professor of Anesthesiology at Emory University, gave a moving and personal Rovenstine lecture on ethical issues at the end-of-life, concerns over futility of care, and the need for recognition and respect of patient autonomy. The body of his talk should be forthcoming within the next 6 to 12 months in Anesthesiology. Additional review of this timely topic may be found in the Council on Ethical and Judicial Affairs report to the AMA (JAMA 1999;281:937-41).
A final highlight of this reporter's experiences at ASA '99 was the transfusion committee meeting that I attended as an adjunct committee member. Three topics were the focus of committee discussion: leukoreduction of red blood cells, plasma solvent/detergent therapy (plasma+SD), and nucleic acid testing (NAT) (see Dr. G. Despotis's refresher course lecture #162 for additional details). Leukocytes are felt to be associated with febrile reactions (febrile, nonhemolytic transfusion reaction [NHTR]) in a significant number of patients, increase risk of infection (particularly with CMV), and appear to play a deleterious role in immunomodulation. An increasing number of red cells can be leukoreduced or administered using a leukocyte filter. This process is a pain in that it limits the ease and speed of infusion. It appears that in 2000, Red Cross supplied blood will be pre-filtered and therefore leukoreduced.
Plasma+SD treatment of pooled batches of plasma is increasingly advocated by some. This treatment eliminates lipid-encapsulated (envelope) viruses such as hepatitis B, C and HIV, but does not eliminate non-envelope viruses (hepatitis A and parvovirus). A recent outbreak of parvovirus has raised concerns over routine use of this pooled product. Careful screening and look-back techniques will limit such problems. However, newer technologies that eliminate both viruses and ABO antigens in plasma are on the horizon. The final area, NAT, was initiated to screen for hepatitis and HIV. This appears to be costly and time-consuming since it is performed on pooled batches of blood at one center. However, more expeditious single unit testing may become available within the foreseeable future.
In closing, there was significant food for thought at the recent ASCCA and ASA annual meetings for anesthesiologists and intensivists. The ongoing discussion of the role and length of CCM experience during anesthesiology residency training and the practice of critical care medicine within the broader clinical context of anesthesiology is undergoing review and discussion by ASA and ASCCA leadership. Their conclusions are likely to mold the future for our specialty. In addition, exciting investigation into optimal mode of ventilation for ARDS patients, inflammatory mediators, and adjunctive therapies in critical care continues to progress.
