Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 2 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 3 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. 4 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. 5 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: 6 • • • • 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. 7 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. 8 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? 9 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 10 • 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. 12 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? 13 5 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”. 14 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 15 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 16 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? 17 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) 18 • 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. 19 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. 20 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. 21 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. 22 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. 23 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. 24 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 25 (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? 26 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. 27 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. 28 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. 29 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. 30 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) 33 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 103 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]. 109 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