What is Intensive Care?
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Intensive care provides a relatively narrow range of treatments based on some simple medical and physiological principles. Although it is true that certain patient groups (eg ECMO patients, bone marrow transplant patients, cardio-thoracic patients or brain-injured patients) may need quite specialist treatment, even in these individuals the same basic supportive care strategies will predominate.
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There are 5 reasons why intensive care works-
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Intensive care is delivered with meticulous attention to detail independent of time of day/day of week; the presence of particular staff or variations in activity/casemix-protocolised standardised care permits the consistent aggregation of marginal gains and avoidance of harm.
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Intensive care is supported by resources (physical and human) which are not available elsewhere in the hospital. The ability to frequently re-assess unstable patients and the response to treatments is particularly important. The use of ultrasound/echo in intensive care provides a good example - assessment is available at any time and is repeatable (ie not static diagnostic modalities but dynamic assessment tools).
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The evidence base is used to make appropriate assessments of the risk : benefit ratio of interventions.
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Intensive care is delivered by an inter-professional team with a flat hierarchy, who prioritise communication and a safety culture.
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Life-prolonging therapies are only given to patients where this is what they want and where it is possible. End-of-life care is prioritised alongside resuscitation.
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The strongest evidence for critical care interventions is in 5 categories-
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Early identification and expert rapid resuscitation of emergency patients using simple principles (early use of oxygen and appropraite fluids; resuscitation checklists/bundles; rapid access to diagnostics; source control; damage control; appropriate use of antibiotics; access to critical care.
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Planned optimization of high-risk surgical patients (comorbidities or complex interventions) and enhanced recovery.
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Avoidance of harm (excessive supplemental oxygen; avoidance of excessive ventilator pressures/volumes; avoidance of high dose steroids in sepsis/Traumatic Brain Injury; avoidance of hypothermia to reduce raised intra-cranial pressure; avoidance of renal-dose dopamine; avoidance of colloids or un-necessary fluid resuscitation; avoidance of un-necessary sedation; avoidance of un-necessary labs or imaging).
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Minimising time in intensive care or on potentially injurious supportive care devices like ventilators or renal-replacement systems (sedation holds; spontaneous breathing trials).
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Studies that focus on improved quality of care (eg communication; end-of-life care; family involvement; rehabilitation).
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Our ICUs appear to contain the hospital's most unstable patients all receiving a bewildering array of advanced monitoring and supportive care interventions. However, it is to misinterpret the true casemix.
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The vast majority of our patients are not healthy people who have suddenly become critically ill. Instead, most of our patients are high-risk (but stable) elective surgical admissions; patients who require prolonged high-dependency nursing and organ support following acute resuscitation; patients with acute problems superimposed on severe chronic (often largely irreversible and multi-organ) health disorders; patients with significant psych-social problems (homelessness; alcohol or drug abuse and prior mental health disorder); patients receiving time-limited or treatment-limited support or end of life-care and (increasingly) delayed discharges.
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Intensive care is also increasingly being provided outside the ICU-outreach; follow-up; rapid response teams like trauma teams; shock teams and sepsis teams.
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Critical Care cannot be viewed in isolation - patient outcomes are highly dependent on 'upstream' factors in primary care, the trauma network, the emergency department & hospital wards. They are also dependent on downstream factors such as hospital bed capacity, the quality of rehabilitation pathways and family support. Clear communication at any transfer of care is important. Critical Care Outreach and Outpatient Follow-up are forming increasingly important in Intensive Care Medicine.
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Inadequate emphasis is often placed on an individual ICU patient's chronic health status; health (or disease) trajectory, baseline quality of life; patient wishes and responsiveness to critical care in relation to outcome. Prognostic uncertainty is very common, but these characteristics are vital in decision making. Baseline blood pressure, exercise capacity, creatinine, bicarbonate all provide useful baseline parameters.
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The art of closed intensive care, is to be open to the views and opinions of other specialty nurses and doctors. Good communication with these teams and services should be reinforced by informing them if there is an unexpected deterioration in their patient and involving them in key clinical decisions. A common agreed position is needed with patients and their families.
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Intelligence of experienced doctors, nurses and AHPs in critical care still outperforms mathematical algorithms, machine learning and artificial intelligence. Don't just look at the numbers.
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Do not just prioritise acute unstable admissions or patients with severe shock/oxygenation failure. Human resources may be better allocated to patients who are 'less' sick, but who may benefit more from intensive care (including the most experienced staff).
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The burden of critical illness and its consequences may stay with our patients and their families for the rest of their lives- this can be physical, cognitive, psychological, and/or socio-economic.
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Be honest with patients and families from the start - it is critical to listen to both, be prepared to say 'we don't know', and be honest about mistakes. Disagreements do occur and allowing more time to pass and obtaining second opinions are good strategies when this occurs. In general patients and families are a lot more forgiving than we expect.
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10-20% of patients admitted to an ICU in the UK go on to die. End-of-life-care is a vital part of intensive care. Dying patients should still be reviewed on ward rounds and patients do not cease to be the responsibility of critical care when they die. Although life-prolonging therapies are frequently and appropriately limited or withdrawn, intensive care is never withdrawn. The possibility of organ and/or tissue donation should be considered in all patients who are receiving end-of-life care. A summary of treatment and care should be written and placed in the hospital record if a patient dies and intensive care doctors can be best placed to write a death certificate.
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Always consider that the diagnosis that has been assigned to a patient may be wrong. It is worth taking a history and examining the patient for yourself, especially at the point of admission to critical care and in long-stay patients who appear to be unresponsive to supportive care or treatments.
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If you are faced with an unstable patient try to be clear why they are unstable - are they hypovolaemic or not; is a high respiratory rate caused by pneumonia, pulmonary oedema or by metabolic acidosis and remember Cis-Atracurium will not resolve a blocked HME.
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In unexpected acute deterioration, it is important to do at least 2 things - look at the recent history (eg what procedures or medications has the patient just had) AND pull back the covers and examine the whole patient (look for evidence of blocked airway, pneumothorax, haemorrhage or sepsis).
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Try to prioritise a critical primary problem definitively - for example, just writing an antibiotic prescription will do nothing in septic shock; if a patient is actively bleeding and in haemorrhagic shock, they need blood products and source control) and inserting an arterial line will be safer and easier once resuscitation is under way.
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Monitors, no matter how fancy, cannot make a patient better.