Download ICU Workbook

INTENSIVE CARE
WORKBOOK - YEAR V
JOHN HUNTER HOSPITAL - ICU
1
INTRODUCTION
This workbook has been developed to assist you during your intensive care attachment. It provides a framework to help students cover many of the important intensive care topics during the short rotation. The workbook contains a series of ICU related subjects that will be useful in preparing you for your internship next year. It is
also an aid to the clinicians with whom you are allocated so they can discuss a
range of concepts with you during the placement.
The topics are aimed at enabling you to recognize and seek appropriate treatment
for critically unwell patients when you become interns. However, you are not con-
1
fined to discussing these topics - if you wish to go into further detail or discuss other
concepts you are encouraged to do so.
In order to gain the maximum benefit from this workbook, it is recommended that
you attempt to answer the set of questions in each topic and then discuss them with
a registrar or consultant at a quiet time of the day (usually in the afternoons). The
topic areas are provided to give an impetus for discussions so do not be disappointed if the conversation ends up heading in a different direction. There are 8
topic areas presented and it is suggested that students try to cover one topic each
day.
Acknowledgements:
Episodes of the following podcasts have been included in these materials:
• SMACC (Social Media and Critical Care)
• iCritical Care (SCCM)
• ICU Rounds (Dr Jeff Guy)
• The Intensive Care Podcast
• Crit-IQ
• EMCrit
This workbook is based on the previous version by Dr David Donelley.
Thanks to Lynn Choo and Philippe Le
Fevre for photographs.
This short textbook, available in the library,
provides a practical introduction to common
clinical problems in the ICU
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2
ICU PROCESSES OF CARE
The ICU is a highly specialized area in medicine and as a medical student you may
be unclear how the system actually works. Discussion on the topic should give
students a general idea about how a patient gets into the ICU, what happens while
they are there and where they go on discharge from the Unit.
The common sources of admissions to the ICU are:
• The Emergency Department
• Planned or unplanned admissions after surgery
• Deteriorating or unstable patients from the wards, often from MET calls
• Retrievals from other hospitals
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The decision to admit a patient to the ICU depends on
whether the patient requires closer monitoring or support
for one or more dysfunctional or failing organ systems, and
whether the patient has a reversible pathology and is likely
to get back to a satisfactory quality of life.
While in the ICU patients are cared for by the Intensive
Care team, in consultation with the admitting team and any
other consulting teams as required.
As patients tend to have a lot of investigations, the ICU
team works closely with radiology and pathology, and in
particular the Infectious Diseases team that visit the ICU
twice a week.
On the ward round each patient is reviewed in detail. For
each of the body systems we consider a list of problems,
and develop a plan of management including investigations and treatments.
It is also important to consider routine “housekeeping” aspects of management such as fluids and nutrition, as well
as prophylaxis against the common complications of hospitalisation and critical care such as pressure areas and
deep venous thrombosis. These are discussed in the following interview and the article regarding the FAST-HUG.
Drs Flower, Wilkinson and
Sheerin discuss
prophylaxis and
“housekeeping
routines” in ICU
The care of patients and their families in the ICU is delivered by a multidisciplinary team including medical and
nursing staff, as well as physiotherapists, pharmacists, social workers, dietitians, and speech pathologists among others.
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Resources
Vincent JL. Give your patient a fast hug (at least) once a
day. Crit Care Med 2005;33:1225-9.
Questions
1. What is a MET call? What criteria are required to make a
“MET call”
2. What are the criteria for ICU and HDU admission?
3. What is the APACHE score? What is it used for?
4. What happens when patients arrive in the ICU?
5. What assessments are done day to day?
6. What are the common complications of ICU admission?
7. What does “FASTHUG” refer to?
8. When do ICU patients get discharged? What happens
when they leave ICU?
• Follow one or more patients from ICU admission to discharge if possible. Review their progress on the daily
ward round and contribute to their management plan.
• Present your patients at the lunchtime meeting.
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3
SHOCK, HAEMODYNAMIC
MONITORING AND SUPPORT
Shock describes the state where there is inadequate oxygen delivery to meet the
metabolic demands of the tissues, resulting in tissue hypoxia.
This imbalance may be due to decreased oxygen delivery, increased metabolic demand or the inability to use oxygen at the cellular level due to mitochondrial dysfunction. Elevated lactate is a sign of anaerobic metabolism, but it is not always present.
Overall, oxygen delivery (DO2) is determined by cardiac output (CO) and arterial
oxygen content (CaO2), which in turn is determined by the haemoglobin concentration (Hb) and the arterial oxygen saturation (SaO2). Consequently, the physiology of
tissue hypoxia may be:
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•
•
•
•
Hypoxic (low pO2)
Anaemic
Stagnant (low cardiac output)
Histiotoxic / cytopathic
Shock may also be due to vasodilatation and maldistribution of blood flow, despite often increased cardiac output.
• Reduced Cardiac Output
• Hypovolemic shock
• Obstructive Shock - e.g. Tension
pneumothorax, cardiac tamponade,
pulmonary embolism
• Cardiogenic Shock - e.g. AMI, myocarditis, valvular disease
• Distributive Shock - e.g. Sepsis, anaphylaxis,
neurogenic shock
Monitoring of patients in shock involves clinical assessment
of organ function, such as level of consciousness and urine
output, as well as non-invasive and invasive monitoring of
haemodynamics and oxygenation.
Dr Jeffrey Guy
explains central
venous oxygen
saturation monitoring
Standard non-invasive monitoring includes ECG, SpO2,
blood pressure. Invasive monitoring includes an arterial
line for continuous blood pressure measurement, and a central venous line for CVP monitoring and central venous oxygen saturation monitoring. Cardiac output can be assessed using a pulmonary artery catheter or a PICCO.
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Dr Jeffrey Guy
talks about cardiac output monitoring
Echocardiography is also used to assess the filling state,
cardiac function and to exclude cardiac tamponade.
Principles of management of shock include optimizing oxygen delivery, and treating the underlying condition. Improving oxygen delivery may involve:
• Intubation and ventilation - increases oxygenation
and decreases oxygen consumption associated
with the work of breathing
• Using fluids, inotropes and vasopressors to manipulate preload, contractility, afterload and heart
rate to optimize cardiac output.
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Questions
1. What are the causes of shock? How can they be classified?
2. Define cardiac output, preload, afterload and myocardial
contractility.
3. What are the early circulatory responses that occur to
compensate for shock?
4. What are the clinical indicators of the presence of shock
during an initial assessment? Is there any correlation
with severity?
5. What are the treatment options and goals for a shocked
patient?
6. How is the response to fluid resuscitation evaluated?
How will the response affect ongoing management decisions?
7. What is early goal directed therapy? When is it appropriate?
8. What complications can be associated with treatment for
shock?
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4
RESPIRATORY FAILURE, AIRWAY
MANAGEMENT AND VENTILATION
Understanding respiratory failure requires you to think about the anatomy and
physiology of the respiratory system, from central control and neuromuscular function to alveolar ventilation and perfusion and the factors affecting diffusion of
gases.
A simple structure for organising the causes of respiratory failure is:
• Airway compromise
• Failure of oxygenation
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• Failure of ventilation (CO2 clearance is proportional to minute ventilation)
Airway Management
The reasons for intubating patients in ICU are to secure the
airway, to facilitate mechanical ventilation to improve gas
exchange, and to reduce the work of breathing.
CPAP and Non-Invasive Ventilation
In patients with mild respiratory failure who are alert and
able to protect their airway, respiratory support can be provided using a tight fitting mask rather than an endotracheal
tube.
Continuous Positive Airway Pressure (CPAP) prevents derecruitment of alveoli, and also reduces cardiac preload and
left ventricular afterload. CPAP improves oxygenation.
Dr Jeffrey Guy
describes different modes of mechanical ventilation
Non-invasive ventilation, often also referred to as Bi-level
Positive Airway Pressure (BIPAP), provides positive pressure during expiration (similar effects to CPAP), and a
higher pressure during inspiration. This increases the tidal
volume and decreases the muscular work done by the respiratory system to achieve a tidal ventilation. Non-Invasive
Ventilation may improve CO2 clearance, as well as improving oxygenation and reducing oxygen consumption and respiratory muscle fatigue.
Mechanical Ventilation
The basic ventilation settings are the FiO2, the breath rate
and the breath “size”. The size of the breath may be deter11
Discussion of the importance of Bag-Valve-Mask ventilation with
Dr Reuben Strayer and Dr Scott Weingart (after long introduction)
FOR A MORE DETAILED
DISCUSSION OF
MECHANICAL
VENTILATION
mined by setting the volume delivered (like filling a petrol
tank), or by setting the inspiratory pressure (like inflating a
tyre).
Resources
West JB. Respiratory Physiology: The Essentials (9th ed)
2012
McNeill G, Glossop A. Clinical applications of non-invasive
ventilation in critical care. Continuing Education in Anaesthesia, Critical Care & Pain 2012;12:33-7.
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Questions
1. Define the terms hypoxia and hypercapnia. What are the
normal reference ranges for PaO2 and PaCO2?
2. Explain Type I respiratory failure. What are some examples of conditions that can cause Type I respiratory failure?
3. Explain Type II respiratory failure. What are some underlying causes for Type II respiratory failure?
4. What investigations are essential for the diagnosis and
evaluation of treatment in respiratory failure?
5. What sedative and muscle relaxant drugs are commonly
used for intubation and what are their relative advantages and disadvantages?
6. What is PEEP? When is it useful?
7. What are some common conditions when CPAP and noninvasive ventilation may be useful?
8. What are the reasons for inserting a tracheostomy in ICU
patients?
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FLUIDS AND ELECTROLYTES, RENAL
FAILURE AND RENAL REPLACEMENT
Abnormalities relating to fluids and electrolytes, and the use of fluids in resuscitation and routine management are very common in intensive care.
To understand these problems, start by reviewing the volumes and composition of
the major fluid “spaces” in the body - the intracellular volume and the extracellular
volume, which in turn consists of the interstitial fluid and plasma. Also recall the major differences in the ionic composition of the intracellular and extracellular fluids,
and the function of the Na/K-ATPase that creates these electrochemical gradients,
while the balance of fluid movement between the intravascular and interstitial fluid
spaces is described by the model of “Starlings forces”.
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Prof John Myburgh talks about
fluid therapy
In critically ill patients, there are combined effects of fluid
administration and abnormal fluid losses, disturbance of
the normal regulatory mechanisms for fluid intake and excretion, damage to the glycocalyx and abnormal shifts of
fluids, particularly from the intravascular space to the interstitial space (or the mythical “third space”).
It is important to consider both the intravascular volume
state, and the electrolyte disturbances separately, particularly in relation to sodium. For example, hyponatremia may
be hypovolemic, when sodium and water have been lost,
with sodium loss in excess of water, or it could be hypervolemic if there is impaired excretion of sodium and water,
with water gain in excess of sodium. In practice the disturbances are often multifactorial, and it is difficult to accurately determine a patient’s volume state.
Other important electolytes to consider include potassium,
calcium, magnesium and phosphate. Consider the causes
and consequences of high or low levels of these electrolytes.
KDIGO Acute Kidney
Injury Guideline
Renal Failure
Acute renal failure affects 15% of ICU patients, and is associated with a mortality of approximately 50%. Common
causes include sepsis, hypovolemia and low cardiac output, major surgery, trauma and rhabdomyolysis, as well as
medications and nephrotoxins including radiographic contrast.
Renal Replacement Therapy
Renal replacement therapy (RRT) is used to correct fluid
and electrolyte abnormalities, acid-base disturbances and
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Dr Jeffrey Guy
describes modes
of Renal Replacement Therapy
uraemia that are due to renal failure. Continuous renal replacement tends to be preferred initially in ICU, as it prevents rapid fluid and electrolyte shifts and haemodynamic
instability that can occur with intermittent haemodialysis
(IHD).
There are two modes by which fluid and electrolytes can be
removed from the patient’s circulation. In practice, the two
modes are often used simultaneously:
• Dialysis - involves the countercurrent flow of dialysis
fluid, separated from the blood by a semipermeable
membrane. Permeant molecules move down their
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concentration gradient and into the dialysis fluid by diffusion.
• Filtration - a hydrostatic pressure gradient forces water and dissolved substances across a membrane.
Resources
Bagshaw SM, Bellomo R, Devarajan P, et al. [Review article: Acute kidney injury in critical illness]. Can J Anaesth
2010;57:985-98.
Questions
1. What are the daily basal requirements for water, sodium
and potassium?
2. Describe the ECG signs of hyperkalemia
3. Outline the steps in the emergency treatment of hyperkalemia
4. How should hyponatremia be treated?
5. What are the potential complications of rapid correction
or hypernatremia and hyponatremia?
6. What objective measures define renal failure?
7. What are the indications for renal replacement therapy?
8. What vascular access is required for RRT?
9. Why does IHD cause greater haemodynamic instability
than CRRT?
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6
SIRS AND SEPSIS
Sepsis is a syndrome that involves the body’s inflammatory response to severe infection. Infections may be community acquired or hospital acquired, and are a frequent cause of unplanned admissions to ICU. Severe sepsis and septic shock have
a significant mortality rate of 25-50%.
Systemic Inflammatory Response Syndrome (SIRS) is not specific for infection, other
causes including trauma, surgery, burns, pancreatitis.
• SIRS - at least two of:
• Pulse rate > 90/min
• Respiratory rate > 20/min (or PaCO2 < 32 mmHg)
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• Temperature >38 C or < 35.5 C
• WBC > 12,000/uL or < 4,000/uL
• Sepsis - SIRS plus presumed or confirmed infection
• Severe Sepsis - Sepsis plus organ hypoperfusion or
dysfunction
• Septic Shock - Sepsis related hypotension not responding to fluid resuscitation, and requiring vasopressors.
Systemic complications of inflammation and cellular dysfunction include acute respiratory distress syndrome
(ARDS), disseminated intravascular coagulation (DIC) and
eventually multi organ dysfunction syndrome (MODS).
Mechanisms for organ dysfunction may include poor tissue
perfusion or impaired cellular oxygen utilisation.
Surviving Sepsis
Guidelines
The basic principles of management of sepsis are outlined
in the Surviving Sepsis Guidelines. Therapies are specific
and supportive. Key features are early recognition, resuscitation, cultures, early antibiotics and source control if possible.
Resources
Dr Scott Weingart discusses the
2012 Surviving
Sepsis Guidelines
Watch this short video on sepsis from Indiana University
“Sepsis Kills” campaign from the Clinical Excellence Commission, NSW including guidelines and smartphone apps.
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Questions
1. What are examples of organ dysfunction in severe sepsis?
2. What are the common hospital acquired infections, and
how is the microbiology of hospital acquired infections
different from community acquired infections?
3. What investigations suggest inadequate tissue perfusion
or impaired oxygen utilisation?
4. Describe the priorities in the management of sepsis.
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7
HEAD INJURIES AND MULTI-TRAUMA
Trauma is one of the most common causes of death between childhood and young
adulthood.
In Australia, trauma is predominantly “blunt”, due to motor vehicle accidents, falls
and assaults. Management of trauma involves a multidisciplinary team and an integrated system that starts with pre-hospital care, and proceeds through the emergency department, to the operating theatres and intensive care. The initial assessment and treatment of patients is guided by algorithms from the EMST / ATLS system.
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Head injuries involve the primary injury that is the physical
damage sustained at the time of impact, and secondary injuries which occur subsequently due primarily to hypoxia
and hypotension. Characteristic findings on CT scan include cerebral contusions, traumatic subarachnoid haemorrhage, subdural and extradural haematomas.
The management of head injuries is directed at preventing
secondary injury, and preventing and treating raised intracranial pressure. Patients with severe head injuries frequently have an External Ventricular Drain (EVD) inserted to
monitor the intracranial pressure, and allow targeting of the
cerebral perfusion pressure.
Resources
EMST
A series of four short talks on traumatic brain injury by
Dr Matthew MacPartlin
Part 1
Part 2
Part 3
Part 4
Brain Trauma
Foundation
Head Injury
Prognosis
Calculator
Trauma.org
Rosenfeld JV, Maas AI, Bragge P, Morganti-Kossmann MC,
Manley GT, Gruen RL. Early management of severe traumatic brain injury. Lancet 2012;380:1088-98.
Haddad SH, Arabi YM. Critical care management of severe
traumatic brain injury in adults. Scand J Trauma Resusc
Emerg Med 2012;20:12.
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Questions
1. Outline the Glasgow Coma Scale (GCS).
2. How is the GCS used to classify the severity of head injury? Does it predict outcome?
3. Outline the rationale behind each of the following principles of management of head-injured patients:
• Normotension
• Normoxia
• Normocapnia
• Normothermia
• Normoglycemia
4. What monitoring is necessary for the assessment and
treatment of severe head injury?
5. How is cerebral perfusion pressure (CPP) calculated?
What is a normal value of CPP?
6. Patients with severe head injury and a high intracranial
pressure (ICP) have a poorer prognosis than those with a
normal ICP. What level of ICP requires therapeutic intervention?
7. Outline a treatment protocol for minimizing intracranial
pressure following brain injury.
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8
NUTRITION IN CRITICAL CARE
Malnutrition is the state in which deficiency of total energy, protein or other nutrients leads to a reduction in body cell mass and organ dysfunction. It can be the result of any combination of inadequate intake, reduced absorption or increased requirements.
Nutrition is an important element of the routine management of ICU patients. Many
patients have a poor nutritional state prior to admission. The stress response in critically ill patients, especially those with trauma or sepsis, causes a hypermetabolic
state resulting in protein catabolism and hyperglycemia.
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Prof Marianne
Chapman on
feeding in the
critically ill
Enteral nutrition is the preferred route of feeding. This improves perfusion of the gut, prevents mucosal atrophy, and
may prevent translocation of gut bacteria.
Parenteral (intravenous) nutrition is an alternative that may
be used if there are contraindications or complications of
enteral nutrition. There has been controversy over whether
TPN is associated with increased infectious complications,
although more recent research has cast doubt on this.
Benefits of nutritional support may include improved wound
healing, decreased infectious complications, and reduced
length of stay.
Resources
Dr Todd Fraser
talks with Dr Andrew Davies
about TPN
Codner PA. Enteral nutrition in the critically ill patient. Surg
Clin North Am 2012;92:1485-501.
Jeejeebhoy KN. Parenteral nutrition in the intensive care
unit. Nutr Rev 2012;70:623-30.
Questions
1. How is a patient’s nutritional status assessed?
2. How are the daily energy requirements for a specific patient calculated? How is the ratio of protein: carbohydrate: fat calculated to make up the energy requirements?
3. Nutritional support can be delivered via three routes oral, enteral (usually nasogastric), and parenteral
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(through a central venous line). What are the advantages of enteral nutrition over parenteral nutrition?
4. What measures can be taken to reduce the risk of aspiration associated with naso-gastric enteral feeding?
5. When should a patient be commenced on total parenteral nutrition (TPN)?
6. What evidence is there to support modification of food
components? What are the aims of these modifications?
7. Potential complications of nutritional support include - 1)
Refeeding syndrome, 2) Overfeeding, and 3) Hyperglycemia. What measures are required to avoid these complications?
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9
ETHICS, COMMUNICATION AND
TEAMWORK IN ICU
The purpose of this tutorial is to get a general idea on common ethical issues occurring in the ICU and the communication skills that are necessary in discussing these
subjects with patients’ family members or guardians.
Management of patients in ICU involves many ethical issues. These discussions often revolve around whether life prolonging treatment should be commenced, and in
circumstances where treatment does not appear to be benefiting the patient,
whether it should be withdrawn.
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Dr Peter Saul talks about death and Intensive Care.
Dr Todd Fraser
and Dr Charlie
Corke discuss
death and dying
in the ICU
ANZICS
DonateLife
Where the patient has previously made their wishes known,
this is an important guide to how the situation should be
managed, however in many cases families are making their
“best guess” about what the patient would want, or making
their own judgement about what is in the best interests of
the patient. You may see the intensive care team talking extensively with patient’s families as well as the admitting
medical team to reach a shared view about how a difficult
situation should be managed. Concepts of futility and quality of life may be discussed, although these are heavily affected by subjective values.
The diagnosis of brain death and the opportunity for organ
donation arises in specific circumstances, such as a severe
traumatic brain injury or a catastrophic intracerebral hemorrhage. Follow the links to the ANZICS statement and the Donate Life website for further information.
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Communication is an essential feature of medicine, and in
the ICU you will observe the importance of communication
between the many members of the medical team and the
patient and their family.
HNE Simulation
Centre
Lapses in communication and teamwork are recognized as
a major source of medical errors, and the intensive care
staff have several initiatives to improve the quality of communication, including simulation training and structured
handovers.
Resources
Curtis JR, Vincent JL. Ethics and end-of-life care for adults
in the intensive care unit. Lancet 2010;376:1347-53.
Luce JM. End-of-life decision making in the intensive care
unit. Am J Respir Crit Care Med 2010;182:6-11.
Wilkinson DJ, Savulescu J. Knowing when to stop: futility in
the ICU. Curr Opin Anaesthesiol 2011;24:160-5.
Jox RJ, Schaider A, Marckmann G, Borasio GD. Medical futility at the end of life: the perspectives of intensive care and
palliative care clinicians. J Med Ethics 2012;38:540-5.
Manthous C, Nembhard IM, Hollingshead AB. Building effective critical care teams. Crit Care 2011;15:307.
Manthous CA, Hollingshead AB. Team science and critical
care. Am J Respir Crit Care Med 2011;184:17-25.
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Questions
1. Define the four basic ethical principles:
• Autonomy
• Beneficence
• Non-Maleficence
• Justice
2. What is medial futility? What should be done if there is
no chance that a patient will survive but the family members insist on advanced care?
3. What is Brain Death? How is it assessed?
4. What other criteria are required to allow for organ donation to be considered? What practicalities must also be
met for organ donation to occur?
5. What communication techniques will be essential during
each of the following situations?
• As a team leader during a medical crisis.
• Inter-professional discussion between clinical teams
where disagreement exists about treatment options.
• Communication with an intubated patient.
• Explanation of critical care interventions and discussion of prognosis during family meetings.
• Negotiating agreement on a withdrawal of treatment
plan.
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10
FURTHER READING
Continuing Medical Education
Give your patient a fast hug (at least) once a day*
Jean-Louis Vincent, MD, PhD, FCCM
LEARNING OBJECTIVES
On completion of this article, the reader should be able to:
1. Interpret the mnemonic “Fast Hug.”
2. Explain the elements of “Fast Hug.”
3. Use this knowledge in a clinical setting.
The author has disclosed that he has no financial relationships or interests in any commercial companies pertaining to this
educational activity.
Wolters Kluwer Health has identified and resolved any faculty conflicts of interests regarding this educational activity.
Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
Objective: To introduce the Fast Hug mnemonic (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control) as a means
of identifying and checking some of the key aspects in the general
care of all critically ill patients.
Design: Not applicable.
Setting: Any intensive care unit at any time.
Patients: All intensive care unit patients.
E
fforts are continually being
made to improve the quality
of patient care in the intensive
care unit (ICU); as elsewhere
in the healthcare system, medical errors
are common and considerable variation
in clinical practice persists even when
evidence-based guidelines are available
(1). Suggested mechanisms to reduce errors and encourage application of the latest clinical study results include proto-
*See also p. 1424.
Head, Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium.
Presented in part at the 33rd Annual Meeting of
the Society of Critical Care Medicine, Orlando, FL,
February 2004, and at the 24th International Symposium on Intensive Care and Emergency Medicine,
Brussels, Belgium, March 2004.
Address requests for reprints to: Jean-Louis Vincent, MD, Department of Intensive Care Erasme University Hospital, Route de Lennik 808 B-1070, Brussels, Belgium. E-mail: [email protected]
Copyright © 2005 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000165962.16682.46
Crit Care Med 2005 Vol. 33, No. 6
Interventions: Dependent on the results of applying the Fast Hug.
Measurements and Main Results: Not applicable.
Conclusions: Application of this simple strategy encourages
teamwork and may help improve the quality of care received by our
intensive care unit patients. (Crit Care Med 2005; 33:1225–1229)
KEY WORDS: feeding; sedation; analgesia; stress ulcer prevention; semirecumbent; glucose control; thromboembolism
cols, checklists, and physicians’ rounds.
Each of these has its place, and indeed, all
three are important. Even though an ICU
should optimally be staffed by intensivists
(2), the present mnemonic could be useful to anybody working in an ICU.
Protocols and Checklists
Protocols have been promoted as enhancing the efficiency, safety, and efficacy
of care; enabling more rigorous clinical
research; and facilitating education (1).
Protocols are increasingly being applied
to specific treatment-management problems, e.g., weaning from mechanical ventilation (3–5), tight glucose control (6 –
8), and adequate sedation (9 –11).
However, although protocols are easily
applied to these relatively simple processes, their usefulness is more debatable
when more complex issues are involved,
for example, the correction of hypovolemia or the treatment of acute lung injury
(12); the treatment of septic shock becomes a real challenge, even with re-
cently published guidelines (13). In addition, although protocols may be
particularly valuable in ICUs of small peripheral hospitals, they are less efficient
in large tertiary care institutions (14).
An alternative to the protocol is the
checklist, widely employed outside medicine. Some have suggested that the ICU
be compared with the aviation cockpit,
where checklists are routinely used to
improve safety. There are indeed some
similarities between the airplane cockpit
and the sophisticated ICU environment in
terms of complex instruments, with
many alarm systems and risks of lifethreatening complications, but there the
comparisons end. Whereas there are relatively few types of planes that any pilot
will be expected to fly, and pilots have
very little freedom in their choice of
route, speed, or timing, intensivists deal
with an almost infinite combination of
disease states (Fig. 1) and have considerable freedom in the choice and intensity
of interventions. In addition, a pilot acts
alone (or with just one co-pilot), whereas
1225
Clinical applications of non-invasive
ventilation in critical care
GBS McNeill MBChB MRCP
AJ Glossop BMedSci, BM, BS, MRCP, FRCA, DICM
Key points
The strongest evidence for
use of non-invasive ventilation
(NIV) is in patients with
respiratory failure secondary
to either chronic obstructive
pulmonary disease or
cardiogenic pulmonary
oedema.
NIV is emerging as an
alternative to MV in a
number of different clinical
situations.
When NIV is commenced
outside critical care, a defined
plan should already be in
place if NIV is unsuccessful.
NIV should not delay
intubation and MV in those
patients who fail to respond
to or deteriorate on NIV.
GBS McNeill MBChB MRCP
Advanced Trainee in Intensive Medicine
Department of Critical Care
Sheffield Teaching Hospitals NHS
Foundation Trust
Sheffield
UK
AJ Glossop BMedSci, BM, BS, MRCP,
FRCA, DICM
Consultant in Anaesthesia and Intensive
Care Medicine and NICE Scholar 2010–
2011 for Evaluation of the Health
Economic Benefits of NIV
Department of Critical Care
Northern General Hospital
Sheffield Teaching Hospitals NHS
Foundation Trust
Sheffield S5 7AU
UK
Tel: þ44 114 271 4195
Fax: þ44 114 226 9342
E-mail: [email protected]
(for correspondence)
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General considerations
Although the likelihood of successful application of NIV will largely depend on the particular clinical setting in which it is applied, some
general considerations can aid success. The importance of explaining the procedure to the
patient, paying close attention to skin integrity,
and appropriate mask interface selection can
play a large role in the success of the intervention. The setting in which NIV is used is also
crucial. It must be appreciated that the scope
for the safe use of NIV in the ward environment is inherently less than that of critical care,
where escalation to invasive ventilation is
rapidly available.
The evidence base for the use of NIV in a
number of different clinical situations has
increased greatly in recent years; however,
there remain a number of contraindications to
its use. These are described in Table 1. While
these general indications and cautions may act
as a guide, the role of NIV in specific clinical
syndromes is inherently more complex.
Guidance based on the available evidence is
outlined below.
Type II respiratory failure
Chronic obstructive pulmonary disease
In acute exacerbations of chronic obstructive
pulmonary disease (COPD), NIV has been
demonstrated in numerous randomized controlled trials (RCTs) and meta-analyses to significantly reduce mortality and complications
when compared with standard medical
therapy.1 As such, it is now considered the firstline therapy in COPD and there is growing evidence that its use may be applicable in patients
with severe acidaemia ( pH,7.25) and hypercarbic coma, conditions previously considered
as contraindications to NIV. This growing evidence base is reflected in the latest BTS guidelines on the use of NIV in acute exacerbations
of COPD. This recently published guidance
emphasizes the need to consider the most appropriate clinical area for NIV to be commenced. Those with severe acidaemia
( pH,7.25) should be managed within a critical
care area. Any possible treatment limitations
should be considered at the time NIV is commenced. Although dedicated respiratory support
units will be suitable for most patients with
acute exacerbations of COPD, if the need for
intubation is anticipated, it may be more appropriate to initiate NIV within a critical care area.
However, some caution should be exercised in patients with COPD and additional
doi:10.1093/bjaceaccp/mkr047
Advance Access publication 7 December, 2011
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 12 Number 1 2012
37
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://ceaccp.oxfordjournals.org/ by guest on March 3, 2014
Reducing the time patients
spend on mechanical
ventilation (MV) may
decrease the risk of several
serious complications.
Tracheal intubation and mechanical ventilation
(MV) are supportive interventions that may be
life saving in critically ill patients but also
involve a significant risk of morbidity and mortality. Averting the need for MV, or reducing
the time patients spend on MV, may decrease
the risk of several serious problems such as
ventilator-associated pneumonia, sedationrelated problems, and sinusitis and may also
improve patient mortality in several different
clinical situations.
Non-invasive ventilation (NIV) is defined as
‘delivery of ventilatory support via the patient’s
upper airway using a mask or similar device’
and includes both continuous positive airway
pressure (CPAP) and non-invasive positive
pressure ventilation (NPPV). NIV was initially
used to treat type II respiratory failure and
prevent the need for MV and the attendant
complications associated with invasive ventilation but is now emerging as a useful alternative
treatment strategy to MV in a number of different clinical situations.
Worldwide, the use of NIV has more than
doubled in the past 10 yr. In the UK where the
previous decade has seen a disproportionate increase in level 2 critical care beds, NIV use has
risen steadily. Yet, large international geographical variations remain and NIV use remains
relatively low in areas such as North America.
Matrix reference 2C02
Can J Anesth/J Can Anesth (2010) 57:985–998
DOI 10.1007/s12630-010-9375-4
REVIEW ARTICLE/BRIEF REVIEW
Review article: Acute kidney injury in critical illness
Article de synthèse: L’insuffisance rénale aiguë lors de maladie
grave
Sean M. Bagshaw, MD • Rinaldo Bellomo, MD • Prasad Devarajan, MD •
Curtis Johnson, MD • C. J. Karvellas, MD • D. James Kutsiogiannis, MD •
Ravindra Mehta, MD • Neesh Pannu, MD • Adam Romanovsky, MD •
Geoffrey Sheinfeld, MD • Samantha Taylor, MN • Michael Zappitelli, MD •
R. T. Noel Gibney, MD
Received: 26 February 2010 / Accepted: 12 August 2010 / Published online: 8 October 2010
! Canadian Anesthesiologists’ Society 2010
Abstract
Purpose This review provides a focused and comprehensive update on emerging evidence related to acute
kidney injury (AKI).
Editor’s Note: This article is the first of two linked special review
articles published in this issue of the Journal. The concept of these
articles emerged from the scientific content of the 2010 Acute Kidney
Injury (AKI) and Renal Support in Critical Illness Symposium,
hosted in Edmonton, Alberta. This review (Part 1) provides a focused
and comprehensive update on emerging evidence in the diagnosis and
classification of AKI, on specific AKI syndromes, and on the
prevention and conservative management of hospitalized patients
with AKI.
Abstracts presented at this meeting were selected on the basis of peer
review by the Scientific Committee and were accepted for
presentation at the AKI 2010 Symposium, and appear as Electronic
Supplementary Material at http://www.springer.com/12630.
Electronic supplementary material The online version of this
article (doi:10.1007/s12630-010-9375-4) contains supplementary
material, which is available to authorized users.
Principal findings Acute kidney injury is a significant
clinical problem that increasingly complicates the course
of hospitalization and portends worse clinical outcome for
sick hospitalized patients. The recent introduction of consensus criteria for the diagnosis of AKI (i.e., RIFLE/AKIN
classification) have greatly improved our capacity not only
to standardize the diagnosis and classification of severity of
AKI, but also to facilitate conducting comparative epidemiologic studies in an effort to better understand the
burden of adult and pediatric AKI and its syndromes (i.e.,
septic, cardio-renal, hepato-renal). The characterization of
several novel AKI-specific biomarkers (i.e., neutrophil
gelatinase-associated lipocalin, kidney injury molecule-1,
and interleukin-18) is extending our understanding of the
pathophysiology of AKI. Moreover, these biomarkers
appear to have clinical relevance for early detection and
they provide prognostic value. These innovations are aiding in the design of epidemiologic surveys and randomized
trials of therapeutic interventions. Strategies for prevention
S. M. Bagshaw, MD (&) ! C. Johnson, MD !
C. J. Karvellas, MD ! D. J. Kutsiogiannis, MD !
A. Romanovsky, MD ! S. Taylor, MN ! R. T. N. Gibney, MD
Division of Critical Care Medicine, Faculty of Medicine and
Dentistry, University of Alberta, 3C1.12 Walter C. Mackenzie
Centre, 8440-122 Street, Edmonton, AB T6G 2B7, Canada
e-mail: [email protected]
C. Johnson, MD ! D. J. Kutsiogiannis, MD
Intensive Care Unit, Royal Alexandra Hospital, Edmonton, AB,
Canada
R. Bellomo, MD
Department of Intensive Care Medicine, Austin Hospital,
Melbourne, Australia
R. Mehta, MD
Division of Nephrology, University of California San Diego
(UCSD) Medical Center, UCSD, San Diego, CA, USA
P. Devarajan, MD
Department of Pediatrics, Cincinnati Children’s Hospital
Medical Center, University of Cincinnati College of Medicine,
Cincinnati, OH, USA
N. Pannu, MD
Division of Nephrology, Department of Medicine, University
of Alberta Hospital, Edmonton, AB, Canada
C. J. Karvellas, MD
Division of Gastroenterology, Department of Medicine,
University of Alberta Hospital, Edmonton, AB, Canada
123
42
Series
Trauma Surgery 1
Early management of severe traumatic brain injury
Jeffrey V Rosenfeld, Andrew I Maas, Peter Bragge, M Cristina Morganti-Kossmann, Geoffrey T Manley, Russell L Gruen
Lancet 2012; 380: 1088–98
See Comment page 1033
This is the first in a Series of
three papers about trauma
surgery
Department of Neurosurgery
(Prof J V Rosenfeld MD) and
National Trauma Research
Institute (Prof J V Rosenfeld,
P Bragge PhD,
M C Morganti-Kossmann PhD,
Prof R L Gruen MD), The Alfred
Hospital, Monash University,
Melbourne, Australia;
Department of Neurosurgery,
Antwerp University Hospital
and University of Antwerp,
Edegem, Belgium
(Prof A I Mass MD); and
San Francisco General Hospital
and University of California,
San Francisco, CA, USA
(Prof G T Manley MD)
Correspondence to:
Prof Jeffrey V Rosenfeld,
Department of Surgery, Alfred
Hospital and Monash University,
The Alfred Centre, Melbourne,
VIC 3004, Australia
[email protected]
For more on the Glasgow
Outcome Scale see http://tbims.
org/combi/gos/
See Online for appendix
For The Global Evidence
Mapping Initiative see http://
www.ntri.org.au/knowledge-hub
For ERABI see http://www.
abiebr.com/
for the International Clinical
Trials Registry Platform see
http://www.who.int/ictrp/en/
1088
Severe traumatic brain injury remains a major health-care problem worldwide. Although major progress has been
made in understanding of the pathophysiology of this injury, this has not yet led to substantial improvements in
outcome. In this report, we address present knowledge and its limitations, research innovations, and clinical
implications. Improved outcomes for patients with severe traumatic brain injury could result from progress in
pharmacological and other treatments, neural repair and regeneration, optimisation of surgical indications and
techniques, and combination and individually targeted treatments. Expanded classification of traumatic brain injury
and innovations in research design will underpin these advances. We are optimistic that further gains in outcome for
patients with severe traumatic brain injury will be achieved in the next decade.
Introduction
Traumatic brain injury is a major global health problem.
Country-based estimates of incidence range from 108 to
332 new cases admitted to hospital per 100 000 population per year.1 On average, 39% of patients with severe
traumatic brain injury die from their injury, and 60%
have an unfavourable outcome on the Glasgow Outcome
Scale (appendix p 2). The incidence of traumatic brain
injury is rising in low-income and middle-income
countries because of increased transport-related injuries,2
and young men (who are over-represented in transport,
work, and recreational injuries) are particularly affected.
In most countries, ageing populations have given rise to
a new cohort—elderly people—who sustain substantial
traumatic brain injuries from fairly low-impact falls.1
Furthermore, blast injury to the brain, which has
distinctive pathological changes, treatment, and prognosis, is common in civilians and military personnel
who are exposed to improvised explosive devices and
suicide terrorist attacks.3
Survivors of severe traumatic brain injury have a low
life expectancy, dying 3·2 times faster than the general
population.4 Furthermore, survivors face prolonged care
and rehabilitation, and have consequent long-term
physical, cognitive, and psychological disorders that
affect their independence, relationships, and employment. In 2007, a conservative estimate of lifetime costs
per case of severe traumatic brain injury was
US$396 331, with costs for disability and lost productivity
($330 827) outweighing those for medical care and
rehabilitation ($65 504).5
Search strategy and selection criteria
Key messages
• Incidence of traumatic brain injury is increasing worldwide
and overall mortality rates have only slightly improved
since 1990. The weighted average mortality for severe
traumatic brain injury is 39%, and for unfavourable
outcome on the Glasgow Outcome Scale is 60%.
• The randomised trial of early decompressive craniectomy
for diffuse brain injury noted worse outcomes after
surgery than with medical treatment. Further trials are
needed. Steroids are not indicated after traumatic brain
injury, except in cases of anterior pituitary insufficiency.
Induced hypothermia and hyperoxia need further
assessment in clinical trials.
• Promising drug candidates are erythropoietin, statins,
ciclosporin-A, tranexamic acid, and progesterone.
• Multimodal monitoring, including cerebral oximetry and
microdialysis, needs further assessment to determine if it
leads to improved outcomes.
• The IMPACT and MRC-CRASH online prediction models
are valuable for clinical practice and research. Promising
new biomarkers are glial fibrillary acidic protein and
ubiquitin carboxy-terminal hydrolase L1.
We searched Medline, evidence-based medicine reviews,
Cochrane Central Register of Controlled Trials, CENTRAL, and
Embase from Jan 1, 2006, to Nov 28, 2011, using the core
terms “brain injuries”, “craniocerebral trauma” and “traumatic
brain injury” and keywords for the following topics:
monitoring, decompressive craniectomy, haematoma
evacuation, steroids, antifibrinolytics, therapeutic
hypothermia, hyperoxia, stem cells, outcomes, predictors of
outcome, and novel predictors of outcome. All searches were
limited to English language studies in human beings. The
appendix (pp 8–12) shows the full search strategies used in
Medline. Reference lists of relevant publications and reviews
were scanned to identify further relevant citations.
7293 citations were screened, 462 reviewed in full text, and
273 were relevant. We further identified trials with two
neurotrauma evidence databases: The Global Evidence
Mapping Initiative and Evidence-Based Review of Acquired
Brain Injury (ERABI). To identify continuing trials, we did a
separate search of the International Clinical Trials Registry
Platform on Jan 31, 2012, for decompressive craniectomy,
haematoma evacuation, aminosteroids, tranexamic acid,
therapeutic hypothermia, hyperoxia, and stem cells.
www.thelancet.com Vol 380 September 22, 2012
56
Enteral Nutrition in the Critically
Ill Patient
Panna A. Codner,
MD
KEYWORDS
! Nutrition ! Critical illness ! Enteral nutrition ! ICU
KEY POINTS
! Early enteral nutrition is the preferred route of nutrition for the critically ill patient.
! Enteral nutrition maintains the intestinal barrier to prevent bacterial translocation.
! Parenteral nutrition is beneficial in the small group of patients who are malnourished on
arrival to the ICU or in patients in whom the intestinal tract is unable to be used for greater
than a week.
! Attention to calories and blood sugar control may reduce complications in patients
receiving parenteral nutrition.
INTRODUCTION
Clinical factors, such as premorbid nutritional status and severity of illness, determine
the overall efficacy of nutritional support. Malnutrition may be defined as “a disorder of
body composition in which macronutrient and/or micronutrient deficiencies occur
when nutrient intake is less than required.”1 Malnutrition leads to reduced organ function, abnormal laboratory chemistry values, and poorer clinical outcome. For all hospitalized patients, the reported prevalence of malnutrition is as high as 50%. Although
difficult to quantify, the incidence in intensive care unit (ICU) patients is closer to
5%. A malnourished patient is more likely to have infectious morbidity, a prolonged
hospital stay, and increased mortality.2 However, not all patients in the ICU need nutritional support, and disease and nutrition exhibit complex interactions. In critical
illness, malnutrition results from abnormal nutrient processing and not starvation.
Each individual patient should receive a nutritional formula specific to their disease
process. Keeping this in mind, it is important to provide early nutritional support during
critical illness. Approaches to nutritional support in the critically ill patient are detailed
later in this article.
The author has nothing to disclose.
Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin,
9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
E-mail address: [email protected]
Surg Clin N Am 92 (2012) 1485–1501
http://dx.doi.org/10.1016/j.suc.2012.08.005
0039-6109/12/$ – see front matter ! 2012 Published by Elsevier Inc.
surgical.theclinics.com
67
Series
Critical Care 2
Ethics and end-of-life care for adults in the intensive care unit
J Randall Curtis, Jean-Louis Vincent
Summary
The intensive care unit (ICU) is where patients are given some of the most technologically advanced life-sustaining
treatments, and where difficult decisions are made about the usefulness of such treatments. The substantial regional
variability in these ethical decisions is a result of many factors, including religious and cultural beliefs. Because most
critically ill patients lack the capacity to make decisions, family and other individuals often act as the surrogate
decision makers, and in many regions communication between the clinician and family is central to decision making
in the ICU. Elsewhere, involvement of the family is reduced and that of the physicians is increased. End-of-life care is
associated with increased burnout and distress among clinicians working in the ICU. Since many deaths in the ICU
are preceded by a decision to withhold or withdraw life support, high-quality decision making and end-of-life care are
essential in all regions, and can improve patient and family outcomes, and also retention of clinicians working in the
ICU. To make such a decision requires adequate training, good communication between the clinician and family, and
the collaboration of a well functioning interdisciplinary team.
Introduction
Critical care is an integral part of hospital care, and the
intensive care unit (ICU) is the setting where patients
are given the most technologically advanced lifesustaining treatments. These treatments are expensive
and resource-intensive, but can sustain life despite
severe and multiple organ dysfunction. The ICU is,
however, also a setting where death is common and endof-life care is frequently provided. Since the focus in
ICUs is on sustaining life, the delivery of highquality end-of-life care can be particularly challenging,
and clinicians often find the dual responsibilities of
saving lives and delivering end-of-life care difficult.
Because of the nature of critical care, difficult decisions
often need to be made about the usefulness of
life-sustaining treatments, not only in terms of the
probability of survival but also the quality of life
associated with survival. Difficult decisions also need to
be made about the fairness of expending substantial
resources on one patient.1 Furthermore, because most
critically ill patients do not have the capacity to make
decisions, the family frequently becomes involved in
discussions about the goals of care and often represents
the values and preferences of the patient.2 The extent
to which the family is directly involved in such
decisions varies according to the countries and cultures;3
however, good communication between the clinician
and family is essential for quality end-of-life care in the
ICU, irrespective of the location.4
Data from observational studies indicate that
end-of-life care in the ICU varies greatly between
countries.5–9 The reasons for this variability have not
been clearly defined, but are probably diverse, including
differences in religion,10 legislation and culture,10,11
organisation of care in the ICU,7,12,13 attitudes of
physicians toward end-of-life care,14 severity of illness
and casemix,7,15 and the physician’s predictions of
www.thelancet.com Vol 376 October 16, 2010
prognosis and future quality of life.15 Variability also
exists within countries16–19 and between intensivists
within hospitals.20
Admissions and triage decisions
The availability of ICU resources vary substantially in
different countries, and decisions about admission,
triage, and end-of-life care vary accordingly. For example,
ICU care is not available in many countries in the
developing world and in rural regions of developed
countries. Even where ICU care is available, the
proportion of hospital beds that are ICU beds differs
between centres.21 The availability of beds in the ICU
will, by necessity, affect decisions about indications for
care in the ICU; this assertion is supported by an
association between the mortality rate in the ICU and
availability of beds in the ICU.21,22 However, the availability
of beds should not affect the ethical principles that guide
the use of intensive care.
An integral part of the ethics of critical care is the
process used for decisions about who needs treatment in
the ICU, and when that treatment is no longer indicated.
Treatment might be judged to be not indicated because
patients are not sick enough for care in the ICU, or
Lancet 2010; 375: 1347–53
Published Online
October 9, 2010
DOI:10.1016/S01406736(10)60143-2
See Editorial page 1273
See Comment page 1275
This is the second in a Series of
three papers about critical care
Division of Pulmonary and
Critical Care Medicine,
Harborview Medical Center;
University of Washington,
Seattle, WA, USA
(Prof J R Curtis MD); and
Department of Intensive Care,
Erasme Hospital; Université
Libre de Bruxelles, Brussels,
Belgium (Prof J-L Vincent MD)
Correspondence to:
Prof J Randall Curtis, Division of
Pulmonary and Critical Care
Medicine Harborview Medical
Center, Box 359762,
University of Washington,
325 Ninth Avenue,
Seattle, WA 98104-2499, USA
[email protected]
Search strategy and selection criteria
We searched the Cochrane Library (1994–2009), Medline
(1994–2009), and Embase (1994–2009) for papers published
in English, using the search terms “ethics”, “end-of-life care”,
or “palliative care” in combination with “critical care” or
“intensive care”. We predominantly selected publications
from the past 5 years, but did not exclude commonly
referenced and highly regarded older publications. We also
searched the reference lists of articles identified by this search
strategy and selected those we judged relevant.
84
1347
Concise Clinical Review
End-of-Life Decision Making in the Intensive Care Unit
John M. Luce1
1
University of California San Francisco, and San Francisco General Hospital, San Francisco, California
Increasingly in the United States and other countries, medical
decisions, including those at the end of life, are made using a shared
decision-making model. Under this model, physicians and other
clinicians help patients clarify their values and reach consensus about
treatment courses consistent with them. Because most critically
ill patients are decisionally impaired, family members and other
surrogates must make end-of-life decisions for them, ideally in
accord with a substituted judgment standard. Physicians generally
make decisions for patients who lack families or other surrogates and
have no advance directives, based on a best interests standard and
occasionally in consultation with other physicians or with review by
a hospital ethics committee. End-of-life decisions for patients with
surrogates usually are made at family conferences, the functioning of
which can be improved by several methods that have been demonstrated to improve communications. Facilitative ethics consultations
can be helpful in resolving conflicts when physicians and families
disagree in end-of-life decisions. Ethics committees actually are
allowed to make such decisions in one state when disagreements
cannot be resolved otherwise.
Keywords: end-of-life care; palliative care; withdrawal of life support;
surrogate decision-making
In 2004, a National Institutes of Health (NIH) State-of-theScience Conference statement (1) defined end-of-life care as
the care provided a person during the final stages of life. End-oflife care is also called palliative care, hospice care, and comfort
care. According to the NIH Conference statement, there is no
exact definition of life’s final stages, nor can a person’s time of
death be accurately predicted. Nevertheless, the end of life most
often is characterized by the presence of disease or disability
that increases progressively and requires symptom management. Such management commonly supersedes or supplants
potentially curative or restorative treatment designed to sustain
life but not necessarily to comfort a person at the time of death.
End-of-life care was hardly a consideration when intensive
care units (ICUs) were developed in the mid-20th century to
provide invasive monitoring and medical interventions to the
critically ill (2). Intensive care medicine was full of promise in
those days, and ICU clinicians, especially physicians, seemed
more interested in saving lives with new technologies than in
comforting dying patients and their families. Nevertheless, as
ICUs proliferated, the limitations of the therapies they provided
were appreciated, along with the realization that some 20% of
patients in countries like the United States die in ICUs or
(Received in original form January 15, 2010; accepted in final form February 24, 2010)
Supported by the author’s personal funds.
Correspondence and requests for reprints should be addressed to John M. Luce,
M.D., Division of Pulmonary and Critical Care Medicine, San Francisco General
Hospital, 1001 Potrero Avenue, Room 5K1, San Francisco, CA 94110. E-mail:
[email protected]
Am J Respir Crit Care Med Vol 182. pp 6–11, 2010
Originally Published in Press as DOI: 10.1164/rccm.201001-0071CI on March 1, 2010
Internet address: www.atsjournals.org
shortly after discharge from them, usually after decisions to
forego life-sustaining therapy have been made (3). As a result,
end-of-life care in the ICU has become a clinical, educational,
and research imperative (4).
Reflecting the strength of this imperative, end-of-life care in
the ICU has been the subject of textbooks (5), journal supplements (6), and statements of the American Thoracic Society (7),
the Society of Critical Care Medicine (8), and other professional
organizations. Rather than repeat the substance of these
publications, I focus in this review on what I consider the most
significant issues in end-of-life care: (1) the importance and
limitations of physician prognostication, (2) medical decision
making for patients with families or other surrogates, (3)
medical decision making for patients without families or other
surrogates, (4) improving decision making for patients with
families or other surrogates, and (5) resolving conflicts in
decision making when physicians and surrogates disagree. I do
not deal with the economic consequences of end-of-life care
because this topic is so large and complex that it merits
a separate review.
THE IMPORTANCE AND LIMITATIONS OF
PHYSICIAN PROGNOSTICATION
However end-of-life decisions are made in the ICU, and
regardless of who makes them, the decisions are profoundly
influenced by physicians’ predictions of patients’ outcomes from
critical illness. Such outcomes may include the likelihood that
the patient will survive a critical illness and what the patient’s
length and quality of life probably will be if he or she leaves the
ICU alive. Physicians may base prognoses on their own
experience or on single- or multiinstitutional studies of specific
diseases, such as acute lung injury (9). Other information has
come from studies of certain age groups, such as the elderly
(10), or of certain interventions, such as mechanical ventilation
(11). Prognosis based on these studies is presumably more
accurate than that of individual physicians. Yet the outcome
of conditions such as acute lung injury changes over time and
with the advent of new treatments (12), limiting the usefulness
of research studies in predicting survival unless they are
frequently updated.
Additional information has been obtained from the use of
multiitem prognostic scoring systems using physiological variables and other data. Perhaps the best known of these systems
is the Acute Physiology and Chronic Health Evaluation
(APACHE), which has gone through four iterations (13).
Systems such as APACHE have been shown to be as accurate
(or inaccurate) as clinical assessment by physicians and nurses
(14). They also have demonstrated good calibration in that the
overall hospital mortality predicted by the systems is comparable to that actually observed in research studies. Nevertheless,
the systems have not discriminated well between individual
survivors and nonsurvivors (15). As a result, the use of prognostic scoring systems remains adjunctive in that they provide
91
Knowing when to stop: futility in the ICU
Dominic J.C. Wilkinsona,b,c and Julian Savulescua
a
Institute for Science and Ethics, Department of
Philosophy, bThe Ethox Centre, Department of Public
Health and Primary Healthcare, University of Oxford,
Oxford, UK and cSchool of Paediatrics and
Reproductive Health, University of Adelaide, Adelaide,
South Australia, Australia
Correspondence to Dominic J.C. Wilkinson, Oxford
Uehiro Centre for Practical Ethics, University of Oxford,
Littlegate House, St Ebbes, Oxford, OX1 1PT, UK
Tel: +44 1865 286 888; fax: +44 1865 286 886;
e-mail: [email protected]
Current Opinion in Anesthesiology 2011,
24:160–165
Purpose of review
Decisions to withdraw or withhold potentially life-sustaining treatment are common in
intensive care and precede the majority of deaths. When families resist or oppose
doctors’ suggestions that it is time to stop treatment, it is often unclear what should be
done. This review will summarize recent literature around futility judgements in intensive
care emphasising ethical and practical questions.
Recent findings
There has been a shift in the language of futility. Patients’ families often do not believe
medical assessments that further treatment would be unsuccessful. Attempts to
determine through data collection which patients have a low or zero chance of survival
have been largely unsuccessful, and are hampered by varying definitions of futility. A
due-process model for adjudicating futility disputes has been developed, and may
provide a better solution to futility disputes than previous futility statutes.
Summary
Specific criteria for unilateral withdrawal of treatment have proved hard to define or
defend. However, it is ethical for doctors to decline to provide treatment that is medically
inappropriate or futile. Understanding the justification for a futility judgement may be
relevant to deciding the most appropriate way to resolve futility disputes.
Keywords
intensive care, medical futility, terminal care, treatment refusal, withholding treatment
Curr Opin Anesthesiol 24:160–165
! 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907
Introduction
It is relatively easy to know when to start intensive care.
Patients with single or multiple organ failure who are not
responding to interventions that are readily available in
hospital wards will likely die if they do not receive
advanced life support. Physiological and clinical criteria
for admission to ICUs are commonplace. However, it is
much harder to reach agreement and develop formal
criteria for who to exclude from admission and on when
to stop intensive care.
At the same time, decisions to withhold or withdraw
potentially life-sustaining treatment (LST) are common;
they precede the majority of deaths in emergency
departments [1] and adult [2!,3–9], paediatric [10,11]
and neonatal [12,13] intensive care. When families
agree with doctors that further treatment should not
be provided decisions are usually straightforward,
particularly if it is clear that this is not something that
the patient themselves would have wanted. However,
when families resist or oppose doctors’ suggestions that
it is time to stop treatment it is much less clear what
should be done. Should doctors unilaterally withdraw or
withhold LST against family (or more rarely patient)
requests? Is it acceptable to continue treatment that
0952-7907 ! 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
medical professionals strongly believe should not be
provided?
The concept of ‘futility’ arose as an attempt to resolve or
to avoid disputes like this. It reflects a perceived need by
doctors to limit patient or family autonomy and a way to
justify a decision not to provide LST [14!!]. In this
article, we discuss three aspects of recent literature
around futility in intensive care: the evolving nature of
‘futility’, attempts to resolve the futility problem through
data collection, and procedural solutions to futility conflicts. In the conclusion we will suggest that a simpler, but
more nuanced understanding of futility may be part of
the way forward.
The evolving nature of futility
The idea of futility is not new. Famously, the Hippocratic
oath included a promise not to treat patients who were
‘overmastered by their disease’ [15]. However, the futility debate in medical and ethical literature really began
in the 1990s. In the previous decade there were a handful
of articles discussing the term. However, after an article
in the Annals of Internal Medicine in 1990 [16] set out
criteria for ‘medical futility’, there was a sharp increase in
the number of MEDLINE citations (Fig. 1). A decade
DOI:10.1097/ACO.0b013e328343c5af
97
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Downloaded from jme.bmj.com on June 10, 2013 - Published by group.bmj.com
Clinical ethics
PAPER
Medical futility at the end of life: the perspectives of
intensive care and palliative care clinicians
Ralf J Jox,1 Andreas Schaider,2 Georg Marckmann,1 Gian Domenico Borasio3
1
Institute of Ethics, History and
Theory of Medicine, University
of Munich, Munich, Germany
2
Department of Internal
Medicine, Hospital of
Traunstein, Traunstein, Germany
3
Chair in Palliative Medicine,
Centre Hospitalier Universitaire
Vaudois, University of Lausanne,
Lausanne, Switzerland
Correspondence to
Dr Ralf J Jox, Institute of Ethics,
History and Theory of Medicine,
University of Munich,
Lessingstrasse 2, 80336
Muenchen, Germany;
[email protected]
Received 9 January 2012
Revised 4 April 2012
Accepted 10 April 2012
ABSTRACT
Objectives Medical futility at the end of life is a growing
challenge to medicine. The goals of the authors were to
elucidate how clinicians define futility, when they
perceive life-sustaining treatment (LST) to be futile, how
they communicate this situation and why LST is
sometimes continued despite being recognised as futile.
Methods The authors reviewed ethics case consultation
protocols and conducted semi-structured interviews with
18 physicians and 11 nurses from adult intensive and
palliative care units at a tertiary hospital in Germany. The
transcripts were subjected to qualitative content
analysis.
Results Futility was identified in the majority of case
consultations. Interviewees associated futility with the
failure to achieve goals of care that offer a benefit to the
patient’s quality of life and are proportionate to the risks,
harms and costs. Prototypic examples mentioned are
situations of irreversible dependence on LST, advanced
metastatic malignancies and extensive brain injury.
Participants agreed that futility should be assessed by
physicians after consultation with the care team.
Intensivists favoured an indirect and stepwise disclosure
of the prognosis. Palliative care clinicians focused on
a candid and empathetic information strategy. The
reasons for continuing futile LST are primarily emotional,
such as guilt, grief, fear of legal consequences and
concerns about the family’s reaction. Other obstacles are
organisational routines, insufficient legal and palliative
knowledge and treatment requests by patients or
families.
Conclusion Managing futility could be improved by
communication training, knowledge transfer,
organisational improvements and emotional and ethical
support systems. The authors propose an algorithm for
end-of-life decision making focusing on goals of
treatment.
INTRODUCTION
If medical treatment is ineffective or unlikely to
achieve an effect that the patient could appreciate
as a benefit, it has been termed futile.1 2 The notion
of medical futility has been heavily criticised on the
grounds that it is ill-defined, blurs medical and
ethical justifications of treatment and contains
negative overtones.2
However, medical futility appears to be a relevant
problem in clinical practice, and a cause of frequent
concern for healthcare professionals, patients, relatives and the law, especially concerning lifesustaining treatment (LST) at the end of life.3e5
Many hospitals have developed futility policies, and
540
states have drafted futility laws.6 A growing
concern is how clinicians should react if patients or
family members demand futile treatment, such as
ineffective chemotherapy for end-stage cancer.7
Given the confusion and controversies of the
discourse, it might be helpful to study what clinicians themselves think about futility.
Such a study is particularly feasible in a country
like Germany where there is no equivalent term for
medical futility and no associated polemical
battlefield. Instead, German law and ethics focus on
the positive opposite of futility, the so-called
medical indication.8
Our aims were to explore how clinicians themselves define medical futility (in German ‘Fehlen
einer medizinischen Indikation’), who they think
should assess this, how they justify performing
futile treatment and how they communicate
futility situations to patients and caregivers.
METHODS
Study design
Because of the explorative nature of our research
aims, and in order to gather in-depth data on the
experiences, attitudes and thoughts of clinicians,
we used a predominantly qualitative mixedmethods approach, analysing protocols of ethics
consultations and interviews with clinicians. The
study was done in accordance with the requirements of the Ethics Committee at our university
hospital.
Document analysis
We analysed 17 ethics consultations at a large
tertiary referral centre in Germany over a 12-month
period. These consultations were sought by clinicians who were uncertain whether to administer
LST, offered by ethically trained palliative care
specialists, and conducted in the setting of a team
conference with or without the patient and his
family. They were in accordance with the standards
of clinical ethics consultation as formulated by the
German Academy of Ethics in Medicine.9 For each
consultation, a complete digital result protocol was
accessed, anonymised and analysed using quantitative content analysis.10 The protocols have
a length of 424e1408 words, were written by the
consultants within 2 days after the consultation,
and summarise the clinical situation, the participants and contents of the discussion, and the
reasons and outcome of decision-making. They
were sent to the care team, included in the patient’s
chart and sometimes given to the patient or family.
Their intention is to document the decision-making
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J Med Ethics 2012;38:540–545. doi:10.1136/medethics-2011-100479
Manthous et al. Critical Care 2011, 15:307
http://ccforum.com/content/15/4/307
VIEWPOINT
Building effective critical care teams
Constantine Manthous*1, Ingrid M Nembhard2 and Andrea B Hollingshead3
Abstract
Critical care is formulated and delivered by a team.
Accordingly, behavioral scientific principles relevant
to teams, namely psychological safety, transactive
memory and leadership, apply to critical care teams.
Two experts in behavioral sciences review the impact
of psychological safety, transactive memory and
leadership on medical team outcomes. A clinician
then applies those principles to two routine critical
care paradigms: daily rounds and resuscitations. Since
critical care is a team endeavor, methods to maximize
teamwork should be learned and mastered by critical
care team members, and especially leaders.
The fragility of critically ill patients leaves little margin
for mismanagement. To offer these most vulnerable
patients the greatest chance of high-quality survival, all
members of the care team must ‘know their stuff ’ and
administer their crafts in a complex, coordinated fashion.
World Cup champions survive the tournament through
teamwork. Since the ‘unit of administration’ in critical
care units is not the physician but rather ‘the team’, it is
reasonable to assume that team dynamics impact outcomes as much - or more - in medicine. However, simply
employing a team-based structure in a critical care unit
does not ensure improved patient outcomes. We here
explore three behavioral science concepts - psychological
safety, transactive memory and leadership - that have
been positively associated with team performance in
previous research. They are harnessed daily - often unconsciously - in most critical care teams, and can be
fortified to enhance care. We then show how these
principles apply and can be cultivated in routine, day-today activities of the critical care team.
*Correspondence: [email protected]
1
Bridgeport Hospital and Yale University School of Medicine, 267 Grant Street,
Bridgeport, CT 06610, USA
Full list of author information is available at the end of the article
© 2010 BioMed Central Ltd
© 2011 BioMed Central Ltd
Lessons from team science
Lesson 1: cultivate psychological safety
Research conducted in health care and other settings
indicates that psychological safety plays a central role in
whether expertise diversity, status differences, and temporary membership - all of which are attributes of health
care teams - facilitate or hinder team effectiveness.
Psychological safety refers to the degree to which individuals perceive their work environment as supportive of
interpersonally risky behavior, such as asking questions,
seeking help, reporting mistakes, raising concerns, or
offering suggestions [1]. Individuals can perceive that
engaging in these behaviors, which is necessary for team
effectiveness, elevates the risk of being seen as ignorant,
incompetent, disruptive or negative [2]. This risk is
minimal in psychologically safe teams; their members
believe that they will not suffer punishment, embarrassment, or any form of negative consequence as a result of
engaging in these behaviors [3].
Research shows that health professionals often feel
psychologically unsafe [4-8]. A series of studies conducted in a variety of hospital units found that only 55% of
staff feel comfortable speaking up even when they
perceived a problem with patient care [5-7]. The sense of
psychological safety mirrors the professional hierarchy. A
study of over 1,400 health professionals from 23 neonatal
intensive care units found that physicians felt significantly
greater psychological safety than nurses, who felt safer
than respiratory therapists [8]. The latter (nonphysicians) reported that it was more difficult to bring up
problems and tough issues. A national study of health
professionals found that non-physicians do not speak up
with concerns because they fear blame, retaliation,
punishment, and belittling response [9]. Between 30%
and 50% of nurses report that nurse input is not wellreceived in their units [6,7].
Studies have shown that patients treated in settings in
which staff feel psychologically unsafe often experience
adverse events [9-11]. For example, a cross-sectional study
of the relationship between hospital climate and clinical
performance showed that hospitals in which staff reported
greater fear of shame and blame had significantly greater
risk of 12 patient safety indicators established by the
Agency for Healthcare Research and Quality [11].
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Concise Clinical Review
Team Science and Critical Care
Constantine A. Manthous1 and Andrea B. Hollingshead2
1
Bridgeport Hospital and Yale University School of Medicine, Bridgeport, Connecticut; and 2Annenberg School of Communication and Journalism,
University of Southern California, Los Angeles, California
Because critical care is administered by multidisciplinary teams, it is
plausible that behavioral methods to enhance team performance
may impact the quality and outcomes of care. This review highlights
the social and behavioral scientific principles of team building and
briefly reviews four features of teams—leadership, psychological
safety, transactive memory, and accountability—that are germane
to critical care teams. The article highlights how team principles
might be used to improve patient care and navigate hospital
hierarchies, and concludes with implications for future educational
and scientific efforts.
Keywords: critical care; team; psychological safety; transactive memory;
leadership
Physicians have always prescribed care for critically ill patients,
but outcomes are superior when physicians act as intensivists to
provide timely direct care and participate collaboratively in
formulation of daily care plans and unit policies (i.e., high-intensity
care) (1–9). Although it is not unexpected that direct, in situ management of critically ill patients—in whom the margin for error
is small—by intensivists is superior to less supervised care, it is
plausible that high-intensity physician staffing entails team and
organizational changes that also contribute to better outcomes.
The functional unit in the intensive care unit (ICU) is the
multidisciplinary critical care team (CCT), which may include
physicians (intensivists), nurses, nurses’ aides, respiratory therapists, nutritionists, pharmacists, physical therapists, pastoral
care providers, clerks, and janitors. Published studies have not
detailed whether changes in team organization and unit culture
coincided with or resulted from changes in physician staffing.
Indirect evidence suggests that observed reductions in patient
mortality are not simply a result of more physician time at the
bedside. Otherwise, adding in-house intensivists to provide care
at night (in addition to day) should have resulted in lower patient
mortality compared with day-only intensivist staffing (10).
If better outcomes are not solely a result of intensivists at the
bedside, possible team-based explanations include:
Physicians could serve to lead, better organize, and collaborate
with team members to assess, redesign (when needed), and
implement more efficient work flows and administer a greater
number of evidence-based therapies;
Physicians could provide services (e.g., education during rounds,
monitoring of clinical outcomes studies for implementation)
that nurture team members from various disciplines to administer medically superior and better-organized care;
Physicians could both model and encourage management techniques and behaviors that are proven in the social and behavioral
sciences to enhance overall performance and unit culture; and
Physicians could serve as institutional voices for critical care
patients and the team in hospital governance.
In this review, we assert that an integrated team approach,
accepted to be at the core of ideal critical care (11, 12), does not
arise by accident or spontaneous generation but rather through
cultivation of principles and practices rooted in the social and
behavioral sciences. We assert that teams are a necessary and
desirable feature of modern healthcare, and that team performance affects patient outcomes (13). Yet, each year, thousands of
intensivists are trained in United States Fellowship Programs,
which are under the regulatory watch of the Accreditation
Council of Graduate Medical Education (14). Leadership and
management skills are listed in ‘‘the essentials’’ for intensivists,
but details of teaching methods and evaluation are conspicuously absent in formal published curricula (15–17). Nonmedical
management skills can impact every feature of critical care
administration, from physical plant, to (quality and disciplinemix of) personnel, to the complex, collaborative choreography
of daily care or resuscitations. Perhaps most important, these
skills can promote a fully engaged, empowered team whose
‘‘culture’’ embraces continuous performance improvement and
patient safety. Whether an ICU director or an attending-of-theday, intensivists’ mastery of management principles is certain to
impact their effectiveness (and satisfaction) on the team, if not
the quality of care provided to patients.
Although the specific committees, titles, and contributors may
differ, intensivists practice in complex organizations and so must
cultivate skills to optimize their effectiveness therein. Figure 1
shows the relationship of one U.S. ICU team to other institutional structures, the organizational context in which it functions.
Composition (i.e., disciplines included) of teams, organization/
reporting structures, and local cultures of care vary remarkably
within and outside the United States. In fact, a multitude of
factors not controlled by the team may vary (Table 1), but we
begin with the assumption that critical care is a team activity, and
as such, some scientific principles underlying team dynamics are
applicable, irrespective of team composition, local practices/infrastructure, or country of practice. Our primary objective here is
to explore ideas and techniques that positively affect team
performance across contexts (18, 19). Our broader goal is to
convince readers that formal education and research in CCT
science are ripe areas for development and could propel substantial improvement in critical care outcomes.
(Received in original form January 31, 2011; accepted in final form March 18, 2011)
Correspondence and requests for reprints should be addressed to Constantine A.
Manthous, M.D., Bridgeport Hospital and Yale University School of Medicine,
267 Grant Street, Bridgeport, CT 06610. E-mail: [email protected]
Am J Respir Crit Care Med Vol 184. pp 17–25, 2011
Originally Published in Press as DOI: 10.1164/rccm.201101-0185CI on March 18, 2011
Internet address: www.atsjournals.org
TEAM SCIENCE
Hard Science—Nature
Our predilection to form teams is likely rooted in both human
nature and nurture. Social evolutionists posit that there are
115