End-of-life care in the intensive care unit

The transition from active, invasive interventions to comfort care for critical care patients is often fraught with misunderstandings, conflict and moral distress. The most common issues that arise are ethical dilemmas around the equivalence of withholding and withdrawing life-sustaining treatment; the doctrine of double effect; the balance between paternalism and shared decision-making; legal challenges around best-interest decisions for patients that lack capacity; conflict resolution; and practical issues during the limitation of treatment. The aim of this article is to address commonly posed questions on these aspects of end-of-life care in the intensive care unit, using best available evidence, and provide practical guidance to critical care clinicians in the UK. With the help of case vignettes, we clarify the disassociation of withdrawing and/or withholding treatment from euthanasia; offer practical suggestions for the use of sedation and analgesia around the end of life, dissipating concerns about hastening death; and advocate for the inclusion of family in decision-making, when the patient does not have capacity. We propose a step-escalation approach in cases of family conflict and advocate for incorporation of communication skills during medical and nursing training.     

End-of-life care in the intensive care unit

End-of-life care in the intensive care unit (ICU) is an oxymoron. Intensive care units appeared in the 1980s only admitting patients for ‘intensive care’. Nowadays the ICU has become one of the few places in the hospital that can provide comfort care to the dying patient. For many doctors on ICU it remains a difficult and problematic area. Yet it is conceptually simple. The difficulty for the doctor is making the decision, for the patient and family, coming to terms with it. This article will focus on how this decision should be made and then on the care that should be provided for the patient. Many of the considerations in decision making are in the General Medical Council guidelines, Treatment and Care Towards the End of Life and this is essential reading before embarking of the process.     

Echocardiography in the intensive care unit

As ultrasound technology improves and ultrasound availability increases, echocardiography utilization is growing within intensive care units. Although not replacing the often-needed comprehensive echocardiographic evaluation, limited bedside echocardiography promises to provide intensivists with enhanced diagnostic ability and improved hemodynamic understanding of individual patients. Routine and emergency echocardiography within the intensive care unit focuses on identifying and optimizing medically treatable conditions in a timely manner. Methods for such goal-directed assessments are presented.     

End-of-life-care in the intensive care unit

The past 4 years has seen an expansion of end-of-life-care (EoLC) in the intensive care unit (ICU), especially in Western countries. ICUs are increasingly becoming the preferred place for the complex dying patient whether intentionally or not. For the majority of patients who die on ICU, it is a planned event with the numbers requiring cardiopulmonary resuscitation reducing. With general ICU mortality being between 20 and 30 %, ‘dying’ is one of the most common ICU diagnoses, making EoLC a daily responsibility for the ICU doctor at all levels of training. Acquiring the knowledge, practical skills, compassion and communication to manage the needs of the diverse population admitted to ICU takes time, but when it is done well this can be a rewarding area of practice. Once it is recognized that a patient is dying, a structured approach and shift in emphasis of patient care has been shown to improve family satisfaction and reduce complaints. This article talks through four real-life cases to bring attention to clinical skills, a structured approach for communication and a decision-making process with reference to the relevant paragraphs of the General Medical Council (GMC) guidelines: Treatment and Care Towards the End-of-Life.     

Reoperation in the intensive care unit

From July 1, 1984, through June 30, 1989, after 1,259 open heart operations, 110 patients (8.7%) underwent 162 early reoperations either in the intensive care unit (144 procedures) or in the operating room (26 procedures). Reexploration for bleeding (49 procedures) (3.9%) and intraaortic balloon removal (50 procedures) (4.0%) were the two most common procedures. Ninety percent and 96% of these procedures, respectively, were performed in the intensive care unit. Mediastinal infections occurred in 4 (6.1%) of 66 patients undergoing repeat mediastinal operations for all indications. No infection occurred after reexploration for bleeding nor did mediastinal infection occur after reoperation in the intensive care unit. Postoperative death in these 110 patients was not related to reoperation except possibly in the case of 1 patient (0.9%). Average transit time to and from the operating room for patients returned there for reoperation was 89.7 minutes. Charges for procedures performed in the operating room were at least twice as great as for those performed in the intensive care unit. This experience supports expanded use of reoperation in the intensive care unit, as it is safe, effective, economical, and convenient.     

Education in the intensive care unit

Intensive care medicine is a newly formed specialty. Intensive care is characterized by a multidisciplinary activity focused on patients whose vital organs are compromised or who are at risk of multiorgan failure. Education in the intensive care unit is a complex activity where the educational and pedagogical process interacts with research, continuous improvement, professionalism, and bioethics. This model provides leadership and excellence in care with high standards of quality, security, solidarity and humanism.     

Sepsis in the intensive care unit

Sepsis remains a major cause of mortality in intensive care. The past 10 years has seen a more uniform, worldwide approach to the management of sepsis, severe sepsis and septic shock. This has resulted in improved survival. It is important to recognize the early symptoms and signs of sepsis; the confused, hypoxic, hypotensive patient with pyrexia, tachycardia, tachypnoea and leucocytosis. Examination must include finding a source for infection and early drainage or debridement. Next take appropriate cultures, and give fluids and broad-spectrum antibiotics. If the picture does not improve over the next 6 hours step-up the treatment to include urine output, blood gases for base excess, lactate, haemoglobin, and glucose. These will guide the management of vasopressors, insulin, fluids, transfusion and bicarbonate. If the hypotension persists (septic shock) the patient should be moved to intensive care. Steroids should be added and additional inotropes. This should be instituted with 24 hours of the start of sepsis. Further advanced care may include mechanical ventilation which requires special consideration. Prevention by screening, stopping cross-infection and appropriate use of antibiotics remains the first priority.     

Sedation in the intensive care unit

Analgesics and sedatives are commonly prescribed in the ICU environment for patient comfort, however, recent studies have shown that these medications can themselves lead to adverse patient outcomes. Interventions that facilitate a total dose reduction in analgesic and sedative medications e.g. the use of nurse controlled protocol guided sedation, the combination of spontaneous awakening and breathing trials, and the use of short acting medications, are associated with improved outcomes such as decreased time of mechanical ventilation and ICU length of stay. This purpose of this review is to provide an overview of the pharmacology of commonly prescribed analgesics and sedatives, and to discuss the evidence regarding best prescribing practices of these medications, to facilitate early liberation from mechanical ventilation and to promote animation in critically ill patients.     

Gastroenterology in the intensive care unit

Hospitalized patients often have poor nutrition, and the metabolic demands of critical illness may exacerbate this. Gastrointestinal (GI) tract dysfunction may be as a result of surgery or contributed to by critical illness itself. This article describes the evidence behind feeding strategies, stress ulceration and the management of upper GI bleeding, selective gut decontamination.     

Jaundice in the intensive care unit

Hyperbilirubinemia, or jaundice, is common in the ICU, with incidence up to 40% among critically ill patients. Unfortunately, it is poorly understood in the critically ill, and too often presents a diagnostic dilemma to the ICU physician. Causes of jaundice in the ICU are multiple; the etiology in any given patient, multifactorial. Acute jaundice can be a harbinger or marker of sepsis, multisystem organ failure (MSOF), or a reflection of transient hypotension (shock liver), right-sided heart failure, the metabolic breakdown of red blood cells, or pharmacologic toxicity. Acute ICU jaundice is best divided into obstructive and nonobstructive. This stratification directs subsequent management and therapeutic decisions.     

Burnout in intensive care unit

AIM: The aim of this paper was to study in intensive care unit (ICU) the impact of variable 'professional role' and 'gender' on the defence mechanisms, on the troubles of mood and on the markers of the burnout syndrome, and to study the correlation between specific defence mechanisms or specific troubles of mood and the onset of burnout syndrome. METHODS: An observational study by administration of psychometric tests was carried out. Twenty-five nurses and 25 doctors working in two differents ICU of the Azienda Ospedaliera-Universitaria Pisana were enrolled. Three psychometric tests concerning the defence mechanisms (Defense Mechanism Inventory), the troubles of mood (Profile of Moods States) and the burnout syndrome (Maslach Burnout Inventory) were administered and the three tests were analysed to study the features of each person enrolled. RESULTS: The study shows the presence within doctors of two dimensions of burnout syndrome (emotional exhaustion in women and depersonalization in men) much greater than nurses. The doctors show the presence of defence mechanism as overturning, aggressiveness and rationalization, and troubles of mood as depression-despondency and aggressiveness-anger. Compared to men, women show turning to one self as defence mechanisms, whereas the men show aggressiveness-anger as trouble of mood. The women doctors show depression-disheartement as trouble of mood, the men doctors show tension-anxiety. We showed a correlation between tiredness-indolence, depression-disheartement and onset of emotional exhaustion, as a correlation between aggressiveness, aggressiveness-anger in man and oncet of depersonalization. Finally we correlated the absence of tension-anxiety as trouble of mood and overturning as defence mechanism with a good personal accomplishment at work. CONCLUSION: The burnout syndrome is present in health-care workers in ICU and it is significantly affected by operating role and gender. We must be aware of this phenomenon in order to study it and to reduce it.     

Cardiac reoperation in the intensive care unit

Background. At our institution, cardiac reoperations are routinely performed in the cardiac intensive care unit, as opposed to taking these patients back to the operating room. Our hypothesis was that reoperation in a cardiac intensive care unit does not increase sternal infection rate.

Methods. A retrospective analysis was performed on 6,908 adult patients undergoing cardiac operation over a 9-year period. Excluding those in cardiac arrest, 340 (4.9%) patients underwent reoperation in the cardiac intensive care unit, of which 289 survived (85%).

Results. Of the 289 patients who survived reoperation in the intensive care unit, 6 developed wound infections that required operative debridement (2.1%), which was not significantly different from those patients not requiring reoperation (1.9%, 121 of 6,497, p = 0.70). Hospital charges for a 2-hour reoperation in the intensive care unit and operating room are approximately $1,972/patient and $5,832/patient, respectively.

Conclusions. Reoperation in the intensive care unit does not increase wound infection rate compared to those without reoperation. Decreased charges, avoiding transport of potentially unstable patients, quicker time to intervention, and convenience are advantages of reoperation in an intensive care unit.     

Healthcare-associated infections in the intensive care unit

The advances made in healthcare in recent years have been remarkable. However, the full benefits of progress have been hampered by the increasing frequency of healthcare-associated infection (HCAI). This is particularly true of the invasive processes involved in providing critically ill patients with intensive care. The rise in multidrug-resistant pathogens has mirrored the increase in incidence of HCAIs. This increasing threat to patient safety is associated with significant morbidity and mortality along with substantial cost implications in the intensive care unit. Although it is unrealistic to believe that HCAIs can be eradicated, it is certainly true that, with due attention to the processes of intensive care, many cases could be prevented.