Evidence-Based Practice of Critical Care E-Book

Clifford S. Deutschman, Patrick J. Neligan

• Publisher: Elsevier
• Year: 2019
• ISBN:
  9780323640695
• Edition: 3
• Topic: Medicine
• Subtopic: Anesthesiology & Pain Management

Approach any critical care challenge using a practical, consistent strategy based on best practices with Evidence-Based Practice of Critical Care, 3rd Edition. Unique, question-based chapters cover the wide variety of clinical options in critical care, examine the relevant research, and provide recommendations based on a thorough analysis of available evidence. Drs. Clifford S. Deutschman and Patrick J. Nelligan, along with nearly 200 critical-care experts, provide a comprehensive framework for translating evidence into practice, helping both residents and practitioners obtain the best possible outcomes for critically ill patients.

• Covers a full range of critical care challenges, from routine care to complicated and special situations.
• Helps you think through each question in a logical, efficient manner, using a practical, consistent approach to available management options and guidelines.
• Features revised and updated information based on current research, and includes all-new cases on key topics and controversies such as the use/overuse of antibiotics, drug resistance in the ICU, non-invasive mechanical ventilation, frequency of transfusions, and duration of renal replacement therapies.
• Provides numerous quick-reference tables that summarize the available literature and recommended clinical approaches.

SECTION 1

Critical Care and Critical Illness

Outline

• 1. Has evidence-based medicine changed the practice of critical care?
• 2. Do protocols/guidelines actually improve outcomes?
• 3. What happens to critically ill patients after they leave the ICU?
• 4. What can be done to enhance recognition of the post-ICU syndrome (PICS)? What can be done to prevent it? What can be done to treat it?
• 5. How have genomics informed our understanding of critical illness?

Chapter 1

Has evidence-based medicine changed the practice of critical care?

Andrew T. Levinson, Mitchell M. Levy

The Evidence-Based Medicine movement, that originated in the mid-1990s, has resulted in monumental changes in critical care medicine. During that period, practice shifted from a reliance on expert opinion to a critical appraisal of the available literature to answer focused clinical questions.^1,2 Systematic examination of what works and what does not, while valuing clinical experience and patient preferences, has led to a surprising and thought-provoking journey that has resulted in dramatic improvements in the care of the critically ill patient. Many of the lessons learned during the evidence-based medicine era would have never been predicted two decades ago.

In this chapter, we describe five important lessons learned in intensive care during the evidence-based medicine era:

1. 1. We need to look beyond single randomized clinical trials (RCTs).
2. 2. It is the small things that make a difference.
3. 3. Accountability is critically important.
4. 4. We often need to do less to patients rather than more.
5. 5. It is the multidisciplinary intensive care unit (ICU) team, not the individual provider, that is the most responsible for good clinical outcomes and high-quality critical care.

Looking beyond single randomized controlled trials

By critically appraising the entire body of literature on specific interventions and clinical outcomes, we have learned many lessons about what is most important in the delivery of critical care. However, we have learned that we must wait before we immediately embrace the results of a single RCT with very impressive results and instead base our clinical practices on more comprehensive, cautious, and critical appraisals of all of the available literature.

The decades of critical care research since the 1990s are filled with stories of impressive findings from single-center RCTs that could not be replicated in larger multicenter RCTs. Unfortunately, in many cases, the initial positive single-center results have been embraced by early adopters, only to have the results refuted by subsequent follow-up trials. The story of tight glycemic control in critical illness is illustrative. A single-center study of the management of hyperglycemia in a population consisting primarily of postcardiac surgical patients found that intensive glucose management with insulin infusion with a target blood glucose of 80 to 110 mg/dL dramatically reduced mortality when compared with a more lenient target blood glucose of 160 to 200 mg/dL.³ The results of this single-center study were embraced by many intensivists and rapidly generalized to a wide variety of critically ill patents. The factors behind this rapid adoption by the field are multiple, including ease of implementation and cost. Unfortunately, a subsequent similar study of medical patients showed no significant benefit of an intensive insulin therapy protocol in the critically ill medical patient.⁴ Ultimately, the most comprehensive multicenter trial of medical and surgical critically ill patients found significantly increased mortality in the group randomized to a tight glycemic control protocol, compared with targeting a blood glucose level of less than 180 mg/dL. This excess mortality was likely due to the much higher rates of severe hypoglycemia.⁵

In 2001, the era of early goal-directed therapy (EGDT) was introduced through the publication of a single-center RCT. EGDT was widely adopted, and multiple subsequent published trials, all prospective cohort series, confirmed its benefit.⁶ More recently, three large RCTs^7–9 failed to demonstrate a survival benefit when protocolized resuscitation was compared with “usual care.” It is possible that these results, at least in part, reflect the effect of the original EGDT trial; the widespread adoption of aggressive, early resuscitation; and the broad-based implementation of the Surviving Sepsis Campaign Guidelines and bundles.¹⁰ If this continues to define usual care, then perhaps it is no longer necessary to mandate specific protocols for resuscitation because it appears that standard sepsis management has evolved to be consistent with published protocols.

The evidence for the use of hydrocortisone in the treatment of septic shock is an example of a sepsis treatment in which the initial promising study was embraced quite early,¹¹ only to be questioned by subsequent conflicting evidence.¹² A multicenter placebo controlled trial of hydrocortisone in septic shock which enrolled 3800 patients, published in 2018, has only increased the ambiguity. It found a quicker resolution in shock but no mortality benefit.¹³ After more than 15 years and multiple large studies we are still awaiting the final answer about the clinical administration of corticosteroids as an adjunctive therapy in septic shock.

Activated protein C is an example of how little we still currently know about the pathobiology of sepsis and the difficulty in developing targeted therapies. Activated protein C, used as an adjunct therapy for patients with sepsis, was initially thought to be quite promising,¹⁴ but was ultimately abandoned after subsequent RCTs failed to duplicate the original results.¹⁵ Newly adopted medications and interventions based on limited data may suffer the same fate.^16,17

Small things make a big difference

The evidence-based era has taught us that small, often neglected or overlooked details of everyday bedside care can play a large role in determining whether our patients survive their ICU stay. Pneumonia that develops after the initiation of mechanic ventilation (ventilator-associated pneumonia [VAP]) is associated with high morbidity and mortality and significantly increased costs for critically ill patients. Several simple targeted interventions to address this problem have significantly reduced VAP rates. Simply keeping our intubated patients’ heads elevated at least 30 degrees rather than leaving them supine (as was customary two decades ago) has resulted in major reductions in VAP.^18,19 In addition, a focus on better oral hygiene of mechanically ventilated patients via the administration of oral chlorhexidine has even further reduced the VAP rates.^20–23

Another simple small intervention in the evidence-based era, the early mobilization of our critically ill patients, has also been found to significantly improve patient outcomes. Critically ill patients were kept immobilized for several weeks in the belief that this was necessary for their recovery. The result was very high rates of ICU-acquired weakness that required prolonged periods of rehabilitation in ICU survivors.²⁴ More recent studies have shown dramatic improvements in functional status and significantly decreased ICU length of stay (LOS) when critically ill patients are mobilized as soon and as much as possible.^25,26

Accountability is important

Another imp...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Contributors
• Preface
• Is hypothermia useful to prevent brain injury after cardiac arrest? In other settings?
• SECTION 1. Critical Care and Critical Illness
• SECTION 2. Basic Respiratory Management and Mechanical Ventilation
• SECTION 3. Non-ARDS and Noninfectious Respiratory Disorders
• SECTION 4. ARDS
• SECTION 5. General Critical Care Management
• SECTION 6. Sepsis
• SECTION 7. Persistent Critical Illness
• SECTION 8. Infection
• SECTION 9. Hemodynamic Management
• SECTION 10. Cardiovascular Critical Care
• SECTION 11. Kidney Injury and Critical Illness
• SECTION 12. Metabolic Abnormalities in Critical Illness
• SECTION 13. Neurological Critical Care
• SECTION 14. Nutrition, Gastrointestinal, and Hepatic Critical Care
• SECTION 15. Endocrine Critical Care
• SECTION 16. Trauma, Surgery, Obstetrics, and Environmental Injuries
• SECTION 17. Hematology Critical Care
• SECTION 18. Critical Care Resource Use and Management
• SECTION 19. Patient Suffering and Other Ethical Issues
• Index