International expert statement on training standards for critical care ultrasonography

Training in ultrasound techniques for intensive care medicine physicians should aim at achieving competencies in three main areas: (1) general critical care ultrasound (GCCUS), (2) “basic” critical care echocardiography (CCE), and (3) advanced CCE. A group of 29 experts representing the European Society of Intensive Care Medicine (ESICM) and 11 other critical care societies worldwide worked on a potential framework for organizing training adapted to each area of competence. This framework is mainly aimed at defining minimal requirements but is by no means rigid or restrictive: each training organization can be adapted according to resources available. There was 100% agreement among the participants that general critical care ultrasound and “basic” critical care echocardiography should be mandatory in the curriculum of intensive care unit (ICU) physicians. It is the role of each critical care society to support the implementation of training in GCCUS and basic CCE in its own country.     

Decision making in the critically ill patient

In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed "high touch" component of "high tech" critical care medicine.     

Management of the critically ill patient in the emergency department: focus on safety issues

The management of the critically ill patient in the emergency department (ED) is an evolving process. Currently there is sufficient evidence substantiating the central role of the ED in the management of critically ill patients. Understanding the tremendous impact ED physicians have in the care of critically ill patients will serve as an impetus for emergency medicine residents to pursue critical care specialty. With the continuous increment of critically ill patients presenting to EDs throughout the country, the nationwide shortage of critical care physicians, and the limited availability of intensive care unit eds throughout hospital systems, there will be an increased focus on managing these patients in the ED. As the field of emergency medicine continues to mature, the ED physician must take notice of the potential risk areas within the management of the critically ill patient to continue to improve these patients' short- and long-term survival.     

A review and analysis of intensive care medicine in the least developed countries

OBJECTIVE: To give critical care clinicians in Western nations a general overview of intensive care medicine in less developed countries and to stimulate institutional or personal initiatives to improve critical care services in the least developed countries. DATA SOURCE: In-depth PubMed search and personal experience of the authors. DATA SYNTHESIS: In view of the eminent burden of disease, prevalence of critically ill patients in the least developed countries is disproportionately high. Despite fundamental logistic (water, electricity, oxygen supply, medical technical equipment, drugs) and financial limitations, intensive care medicine has become a discipline of its own in most nations. Today, many district and regional hospitals have units where severely ill patients are separately cared for, although major intensive care units are only found in large hospitals of urban or metropolitan areas. High workload, low wages, and a high risk of occupational infections with either the human immunodeficiency virus or a hepatitis virus explain burnout syndromes and low motivation in some health care workers. The four most common admission criteria to intensive care units in least developed countries are postsurgical treatment, infectious diseases, trauma, and peripartum maternal or neonatal complications. Logistic and financial limitations, as well as insufficiencies of supporting disciplines (e.g., laboratories, radiology, surgery), poor general health status of patients, and in many cases delayed presentation of severely sick patients to the intensive care unit, contribute to comparably high mortality rates. CONCLUSION: More studies on the current state of intensive care medicine in least developed countries are needed to provide reasonable aid to improve care of the most severely ill patients in the poorest countries of the world.     

A critical care nurse's guide to intra abdominal hypertension and abdominal compartment syndrome.

Abdominal compartment syndrome (ACS) is a life-threatening syndrome that is increasing in incidence amongst critically ill patients. A 2005 survey of critical care nurses revealed that there were recognised knowledge deficits of ACS amongst surveyed nurses. The purpose of this review is to inform critical care nurses about ACS and its antecedent, intra abdominal hypertension (IAH). Detection techniques, causes, clinical manifestations and pathophysiology of IAH and ACS will be outlined and medical and nursing management will be reviewed. The incidence of ACS is reported to be up to 35% in the intensive care population with reduced survival when compared to other intensive care patients. Physiological changes that occur with ACS include compromise to the cardiovascular, respiratory, renal and neurological systems and development of metabolic acidosis. Management may incorporate percutaneous drainage of ascitic fluid, use of muscle relaxants, prone positioning and surgical intervention to open, decompress and gradually close the abdomen. Throughout this care the critical care nurse should ensure accurate monitoring of organ function, assessment for recurrence of ACS as well as the amount and type of drainage, appropriate wound management and provision of physical and psychosocial support of the patient. These aspects of care have the potential to impact significantly on patient outcome.     

Secondary transport of the critically ill and injured adult

There is significant interest in the secondary transport of the critically ill and injured. High profile cases entailing the long distance transfer of patients have highlighted the lack of availability of critical care beds and appropriate systems for transferring this patient group. These and other issues have culminated in the release of Comprehensive Critical Care by the Department of Health in 2000. It has been shown that a large number of critical care transfers originate in the emergency department. The transportation of patients has not traditionally been part of the core curriculum of emergency medicine specialists in the UK. It is imperative that clinicians have an understanding of the issues surrounding transportation of the critically ill and injured. This should include appreciation of the local and regional organisational frameworks implemented for this patient group. This review describes the core issues relevant to emergency medicine relating to the transportation of the critically ill and injured.     

A personal reflection: the intimacy of dying: an act of presence.

The focus of critical care education is usually on the development of knowledge and skills needed to manage care for the critically ill patient. In today's intensive care units, what is also needed is the education and development of the skills that enable nurses the ability to enter into a relationship with the patients and families that touch the spirit, and provide another dimension to healing.     

Variability in alignment of central venous pressure transducer to physiologic reference point in the intensive care unit–A descriptive and correlational study

BackgroundThe phlebostatic axis is the most commonly used anatomical external reference point for central venous pressure measurements. Deviation in the central venous pressure transducer alignment from the phlebostatic axis causes inadequate pressure readings, which may affect treatment decisions for critically ill patients in intensive care units.AimThe primary aim of the study was to assess the variability in central venous pressure transducer levelling in the intensive care unit. We also assessed whether patient characteristics impacted on central venous pressure transducer alignment deviation.MethodsA sample of 61 critical care nurses was recruited and asked to place a transducer at the appropriate level for central venous pressure measurement. The measurements were performed in the intensive care unit on critically ill patients in supine and Fowler's positions. The variability among the participants using eyeball levelling and a laser levelling device was calculated in both sessions and adjusted for patient characteristics.ResultsA significant variation was found among critical care nurses in the horizontal levelling of the pressure transducer placement when measuring central venous pressure in the intensive care unit. Using a laser levelling device did not reduce the deviation from the phlebostatic axis. Patient characteristics had little impact on the deviation in the measurements.ConclusionThe anatomical external landmark for the phlebostatic axis varied between critical care nurses, as the variation in the central venous pressure transducer placement was not reduced with a laser levelling device. Standardisation of a zero-level for vascular pressures should be considered to reduce the variability in vascular pressure readings in the intensive care unit to improve patient treatment decisions. Further studies are needed to evaluate critical care nurses' knowledge and use of central venous pressure monitoring and whether assistive tools and/or routines can improve the accuracy in vascular pressure measurements in intensive care units.     

ICUs worldwide: an overview of critical care medicine in South Africa

South Africa has undergone rapid changes in the political and social arenas since 1994. With new policy-makers in the Department of Health, the distribution of health care resources are being rationalised and redirected to benefit the majority of the previously disadvantaged population of the country. The role and rationalisation of intensive care medicine has to be re-evaluated to ascertain that it is at a level appropriate for a developing country. Despite progress made, the subspecialty of intensive care medicine faces challenges from changing disease patterns and from lack of human and financial resources as these are redirected to primary health care and other priorities facing the country.     

Measuring nursing workload in intensive care: an observational study using closed circuit video cameras

BACKGROUND: There is an increasing demand for intensive care provision in the United Kingdom (UK), partly because of a national shortage of intensive care beds. The problem is compounded by the current method for calculating the nurse: patient ratio using a Nurse Workload Patient Category scoring system or similar adaptations used in many intensive care units. This ratio is calculated by using patient category or dependency scales, which operate on the assumption that the more critically ill the patient, the more nurse time is needed to care for the patient. However, many mechanically ventilated critically ill patients (allocated a high category of care) may need less nursing care than patients who are self-ventilating and allocated a lower level of dependence. PURPOSE: In this study, a video recorder was used to document nurse activity for 48 continuous shifts in two intensive care units to determine the accuracy of the Nursing Workload Patient Category scoring system in measuring nurse workload. METHODS: The video data were correlated later with the Patient Category allocated to the patient by the nurse at the time. RESULTS: The results of this observational study demonstrated that, despite complex care needs, a high percentage of nursing activities observed in each unit consisted of low skill activity. Furthermore, nurses spent less time with patients categorized as in need of intensive care than those in need of high dependency care in both units. CONCLUSION: The findings suggest that existing nurse:patient ratio classifications may be inappropriate, since nurses spent less time with critically ill patients. Radical reconsideration of nursing levels and skill mix might make it possible to increase intensive care provision because fewer nurses would be needed to staff each bed. The findings support alternative and more flexible systems for assessing workload and the use of different nurse:patient ratios.     

ICUs worldwide: An overview of critical care medicine in South Africa

South Africa has undergone rapid changes in the political and social arenas since 1994. With new policy-makers in the Department of Health, the distribution of health care resources are being rationalised and redirected to benefit the majority of the previously disadvantaged population of the country. The role and rationalisation of intensive care medicine has to be re-evaluated to ascertain that it is at a level appropriate for a developing country. Despite progress made, the subspecialty of intensive care medicine faces challenges from changing disease patterns and from lack of human and financial resources as these are redirected to primary health care and other priorities facing the country.     

ICUs worldwide: A brief description of intensive care development in Argentina

The present commentary reviews the development and present situation of critical care medicine in Argentina. Critical care has a long history in our country that began in 1958. Its development has not been uniform, and followed the political and economic troubles of the country, particularly those of its health system. Nevertheless, high quality care for critically ill patients, in both human and technological terms, has been achieved in Argentina.     

Sedation in the intensive care unit

OBJECTIVE: To describe the goals of sedative use in the intensive care unit and review the pharmacology of commonly used sedative drugs as well as to review pertinent publications in the literature concerning the comparative pharmacology of these drugs, with emphasis on outcomes related to sedation and comparative pharmacoeconomics. DATA SOURCES: Publications in the scientific literature. DATA EXTRACTION: Computer search of the literature with selection of representative articles. SYNTHESIS: Proper choice and use of sedative drugs is based on knowledge of the pharmacology of commonly used agents and is an essential component of caring for patients in the intensive care unit. The large variability in pharmacokinetics and pharmacodynamics in the critically ill make it difficult to directly compare agents. Midazolam provides rapid and reliable amnesia, even when administered for low levels of sedation. Propofol may be useful when deeper levels of sedation and more rapid awakening are required. Lorazepam can be used for long-term sedation in more stable patients if rapidity of effect is not required. Further investigation in assessment of depth of sedation in the critically ill is needed. Continued study of costs, side effects, and appropriate dosing strategies of all sedative agents is needed to answer questions not sufficiently addressed in the current literature. Conclusion: An individualized approach to sedation based on knowledge of drug pharmacology is needed because of confounding variables including concurrent patient illness, depth of sedation, and concomitant use of analgesic agents. (Crit Care Med 2000; 28:854-866) KEY WORDS: sedation; anxiolysis; critical care; midazolam; lorazepam; propofol; benzodiazepines; intensive care unit; pharmacoeconomics; critical illness     

Respiratory controversies in the critical care setting. When caring for critically ill patients, do clinicians have a responsibility to be innovative and try unproven approaches when accepted approaches are failing?

As the first paper in this Journal Conference on intensive care unit controversies, the editors wished us to set the tone for the debate by discussing the ethics of medical "adventurism" in the intensive care unit. More life-or-death decisions are made in the intensive care unit than elsewhere in the hospital, and the critical care specialist often sees himself or herself as a warrior in a battle with death. This adrenaline-charged calling attracts highly intelligent, hard-working, and compassionate caregivers, as well as fiercely independent clinicians. The result of this is that critical care specialists passionately debate about the meaning and application of published "evidence" and this leads to thoughtful debate, as exemplified by the papers in this and the next issue of Respiratory Care, as well as thoughtless and often dangerous disregard for evidence-based medicine. Physicians are morally obligated to provide the best and most appropriate care possible for their patients, but when accepted approaches are failing and a critically ill patient is getting worse, the critical care physician must make a decision regarding innovative therapy, based on the patient's prognosis, the available evidence, the resources on hand, the expertise of the physicians, and the values of the patient and the physician. This decision may lead, at times, to trying unproven and innovative strategies to achieve a clinical goal. In such cases, it is to be hoped that this can be done in such a way that data are formally and prospectively collected to increase our knowledge.     

Guidelines for critical care medicine training and continuing medical education

OBJECTIVE: Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care. PARTICIPANTS: A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine. SCOPE: Physician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization. DATA SOURCES AND SYNTHESIS: Relevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline. CONCLUSIONS: Guidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.     

临床医学专业学生对重症医学专业认知度的调查及提升对策

目的调查临床医学专业本科学生对重症医学专业的认知度,并为提升重症医学专业认知度提出有效建议和对策。 方法采用问卷调查方法,应用分层抽样,调查广州医科大学临床医学专业2015至2019级共250名本科学生对重症医学专业的专业认知情况,包括学生基本情况、专业认识程度、提升意愿及方法。 结果96.0%的学生认为需要重视重症医学学习,71.6%的学生认为重症医学专业发展前景较好,40.8%的学生对重症医学感兴趣,感兴趣的原因主要是重症医学具有挑战性以及未来可以救助危重症患者而有责任感和成就感。然而,仅9.2%的学生认为自己对重症医学学科有一定了解,仅7.2%的学生会考虑报考重症医学专业研究生或成为重症医学科医生,仅10.0%的学生会考虑参加重症医学专业规范化培训。对于从事重症医学的职业顾虑由高到低依次是高强度工作,精神压力大,专业技术要求高,风险高,医疗纠纷频繁。此外,94.4%的学生愿意通过各种途径提升自身对重症医学专业的认识。 结论临床医学专业学生对重症医学专业的了解度、兴趣度和择业意向均有待提高,本学科专家需积极了解和响应学生实际情况及需求,与医学院校及教学医院共同探讨学科教学举措,加强临床医学专业学生的重症医学学科教育。     

Informed consent in the intensive care unit: ensuring understanding in a complex environment

PURPOSE OF REVIEW: Informed consent in the intensive care unit continues to receive marked attention. As greater numbers of patients enter into the intensive care unit with devastating illness, patients and families are faced with more complex medical problems and decisions regarding therapy. Furthermore, research investigations of critical illness add a level of complexity to informed consent and decision making that mandates a careful approach. RECENT FINDINGS: Publications in the past year evidence the potential obstacles for appropriate informed consent. Physicians demonstrate variability in interpretation for the need for informed consent and frequently lack formal training in communicating informed consent. Critical care researchers must communicate the goals and benefits of trial participation carefully, avoiding the demonstrably common pitfall of therapeutic misconception. Excellent consensus statements now exist to guide the researcher in pursuing critical care research, creating informed consent documentation, and recognizing the appropriate setting for waiver of consent. As expected, extended discussion is the most effective tool for improving the quality of informed consent. SUMMARY: Quality of informed consent for the critically ill improves as attention is paid to standardizing indications and formalizing training for physicians. In research, conflicts of interest should be recognized and used to guide the investigator's dialogue on research benefits and risks. Patient safety must be maintained as the primary priority; however, waiver of consent may be considered in situations in which the benefit to medical knowledge far exceeds patient risk.     

Critical care without walls

Critical care medicine is a relatively young specialty that was developed in response to potentially reversible life-threatening illness and was facilitated by developments such as new drugs, support equipment, and monitoring technology. It has been largely practiced within the four walls of an intensive care unit (ICU). However, now there are increasing numbers of critically ill and at-risk patients in acute hospitals who are suffering potentially preventable, serious complications that may result in death because of a lack of appropriate systems, skills, and expertise outside of the ICU. Critical care specialists are expanding their roles beyond the four walls of their ICUs and becoming involved with strategies such as the medical emergency team, a concept designed to recognize critical illness early and to respond rapidly to resuscitate patients wherever they are in the hospital.     

When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature

BACKGROUND: Receiving care in an intensive care unit can greatly influence patients' survival and quality of life. Such treatments can, however, be extremely resource intensive. Therefore, it is increasingly important to understand the costs and consequences associated with interventions aimed at reducing mortality and morbidity of critically ill patients. Cost-effectiveness analyses (CEAs) have become increasingly common to aid decisions about the allocation of scarce healthcare resources. OBJECTIVES: To identify published original CEAs presenting cost/quality-adjusted life year or cost/life-year ratios for treatments used in intensive care units, to summarize the results in an accessible format, and to identify areas in critical care medicine that merit further economic evaluation. METHODS: We conducted a systematic search of the English-language literature for original CEAs of critical care interventions published from 1993 through 2003. We collected data on the target population, therapy or program, study results, analytic methods employed, and the cost-effectiveness ratios presented. RESULTS: We identified 19 CEAs published through 2003 with 48 cost-effectiveness ratios pertaining to treatment of severe sepsis, acute respiratory failure, and general critical care interventions. These ratios ranged from cost saving to 958,423 US dollars/quality-adjusted life year and from 1,150 to 575,054 US dollars/life year gained. Many studies reported favorable cost-effectiveness profiles (i.e., below 50,000 US dollars/life year or quality-adjusted life year). CONCLUSIONS: Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money. However, overall there is a paucity of CEA literature on the management of the critically ill, and further high-quality CEA is needed. In particular, research should focus on costly interventions such as 24-hr intensivist availability, early goal-directed therapy, and renal replacement therapy. Recent guidelines for the conduct of CEAs in critical care may increase the number and improve the quality of future CEAs.