Anaesthesia, Pain, Intensive Care and Emergency - Part 1 docx

ANTONINOGULLO, M.D.Head, Department of Anaesthesia and Intensive Care Head, Postgraduated School of Anaesthesia and Intensive Care Catania University Hospital Catania, Italy Library of C

A Gullo (Editor)

Anaesthesia, Pain, Intensive Care and Emergency – A.P.I.C.E Proceedings of the

21stPostgraduate Course in Critical Care Medicine

Venice-Mestre, Italy –November 10-13, 2006

21st Postgraduate Course in Critical Care Medicine

Venice-Mestre, Italy – November 10-13, 2006

Springer

ANTONINOGULLO, M.D.

Head, Department of Anaesthesia and Intensive Care

Head, Postgraduated School of Anaesthesia and Intensive Care

Catania University Hospital

Catania, Italy

Library of Congress Control Number: 2006935691

ISBN 10 88-470-0570-1 Springer Milan Berlin Heidelberg New York

ISBN 13 978-88-470-0570-9 Springer Milan Berlin Heidelberg New York

This work is subject to copyright All rights are reserved, whether the whole or part of the material

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Springer is a part of Springer Science+Business Media

Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book In every individual case the user must check such information by consulting the relevant literature.

Cover design: Simona Colombo

Typesetting and printing: Arti Grafiche Stella, Trieste, Italy

Chapter 2 – Genetics and molecular biology in acute lung injury

R VASCHETTO, J HAITSMA, H ZHANG 11

Chapter 3 – Lung, respiratory mechanics, artificial ventilation

A KOUTSOUKOU, J MILIC- EMILI 19

Chapter 4 – The pressure-volume curve

V.R CAGIDO, W.A ZIN 29

Chapter 5 – Methods for assessing expiratory flow limitation during tidal breathing

N.G KOULOURIS, S.-A GENNIMATA, A KOUTSOUKOU 41

Chapter 6 – How to ventilate brain-injured patients in respiratory failure

P PELOSI, P SEVERGNINI, M CHIARANDA 53

Chapter 7 – Helping surgical patients to give up smoking

D.O WARNER 69

Chapter 8 – Respiratory issues and ventilatory strategies for morbidly obese patients

J SPRUNG 75

FLUID AND ELECTROLYTE EMERGENCY

Chapter 9 – Fluid and electrolyte emergency

J BOLDT 87

V

Chapter 10 – Electrolyte emergencies, anion gap, osmolality

F SCHIRALDI, G GUIOTTO, L MORELLI 97

Chapter 11 – Acute renal failure

M PALAZZO 109

Chapter 12 – Acute liver failure

P FELTRACCO, M.L BREZZI, C ORI 129

INFECTIONS AND SEPSIS

Chapter 13 – Pneumonia in ventilated patients Severe Gram negative infections;

the impact on mortality and its prevention

D.F ZANDSTRA, H.K.F.VANSAENE 143

Chapter 14 – Gram-positive ventilator-associated pneumonia: impact on mortality

A.R DEGAUDIO, S RINALDI 155

Chapter 15 – Fungal infections in the ICU

A DEGASPERI, A CORTI, L PERRONE 163

Chapter 16 – Focus on the diagnosis and treatment of severe meningitis

R LUZZATI, D GIACOMAZZI 171

Chapter 17 – Plasma filtration in sepsis: a research protocol

S LIVIGNI, M MAIO, G BERTOLINI 181

HIGHLIGHTS ON CIRCULATORY FAILURE, CPR AND TRAUMA

Chapter 18 – The cell in shock

M.M MORALES, H PETRS-SILVA 191

Chapter 19 – Tissue partial pressure of carbon dioxide tension measurements

and microcirculation visualisation New techniques for the study of low flow states

G RISTAGNO, W TANG, M.H WEIL 203

Chapter 20 – Ventricular fibrillation and defibrillation: contemporary understanding

of mechanisms

R.D WHITE 215

VI

Chapter 21 – Arterial waveform analysis to determine cardiovascular parameters

S SCOLLETTA, B BIAGIOLI, P GIOMARELLI 225

Chapter 22 – The Utstein style for the reporting of data from cardiac arrest

Chapter 25 – Standards of care in operating theatres

F GRÜNE, T OTTENS, M KLIMEK 281

Chapter 26 – Audit

M KLIMEK, F GRÜNE 291

Chapter 27 – Focus on entropy and surgical stress index

M SORBELLO, S MANGIAMELI, A GULLO 301

Chapter 28 – Neuraxial anaesthesia and anticoagulation

OBSTETRICS AND PAEDIATRICS

Chapter 33 – Obstetrics at high risk

R ALEXANDER, N VOLPE 365

Chapter 34 – Resuscitation of the newborn

D TREVISANUTO, N DOGLIONI, F MARIO 377

Chapter 35 – Regional anaesthesia in neonates

M ASTUTO, D SAPIENZA, G RIZZO 385

Chapter 36 – Locoregional anaesthesia in children

N DISMA, G ROSANO, D LAURETTA 397

Chapter 37 – Management of CRRT in paediatrics

G ZOBEL, S RÖDL, E RING 405

Chapter 38 – Severity scores in paediatric intensive care units

I SALVO, A WOLFLER, A MANDELLI 413

Chapter 39 – Analgesia and sedation during mechanical ventilation in paediatrics

M L MASSONE, L MANFREDINI, G OTTONELLO 421

COMPUTING

Chapter 40 – Latency reduction in clinical and translational research

C.-H HUANG 437

CRITICAL CARE BLEEDING

Chapter 41 – New frontiers in critical bleeding

S BUSANI, L DONNO, M GIRARDIS 449

Chapter 42 – Evaluation of performance of ICUs

J.R LEGALL 455

VIII

Alexander R.

Department of Anaesthetics,

Worcester-shire Royal Hospital, Worcester (UK)

Astuto M.

Department of Anaesthesia and Intensive

Care, Postgraduate School of Anaesthesia

and Intensive Care, Catania University

Hospital, Catania (Italy)

Bertolini G.

GiViTI Coordinating Centre, Laboratory

of Clinical Epidemiology, “Mario Negri”

Institute for Pharmacological Research,

Ranica-BG (Italy)

Biagioli B.

Department of Cardiothoracic

Anaesthe-sia and Intensive Care Unit, University of

Siena (Italy)

Boldt J.

Department of Anaesthesiology and

In-tensive Care Medicine, Klinikum der

Stadt Ludwigshafen (Germany)

Brezzi M.L.

Department of Pharmacology and

Anaesthesiology University Hospital of

Padua (Italy)

Busani S.

Anaesthesia and Intensive Care Unit I,

Modena University Hospital and Modena

and Reggio Emilia University (Italy)

Cagido V.R.

Laboratory of Respiration Physiology,

Carlos Chagas Filho Institute of

Biophy-sics, Federal University of Rio de Janeiro

(Brazil)

Chiaranda M.

Department for the Environment, Healthand Safety, University of Insubria –Anaesthesia and Intensive Care Unit B,District Hospital and Macchi Foundation,Varese (Italy)

Corti A.

2nd Anaesthesia, Intensive Care and dominal Transplantation Unit, NiguardaCa’ Granda Hospital, Milan (Italy)

Ab-De Gasperi A.

2nd Anaesthesia, Intensive Care and dominal Transplantation Unit, NiguardaCa’ Granda Hospital, Milan (Italy)

Ab-De Gaudio A.R.

Department of Critical Care, Section ofAnaesthesiology and Critical Care, Uni-versity of Florence (Italy)

Disma N.

Department of Anaesthesia and IntensiveCare, Catania University Hospital,Catania (Italy)

Doglioni N.

Paediatric Department, School of cine, University of Padua, Azienda Ospe-daliera Padua (Italy)

Medi-Donno L.

Anaesthesia and Intensive Care Unit I,Modena University Hospital and Modenaand Reggio Emilia University (Italy)

Feltracco P.

Department of Pharmacology andAnaesthesiology University Hospital ofPadua (Italy)

List of Contributors

IX

Gennimata S.-A.

Respiratory Function Laboratory,

Depart-ment of Respiratory Medicine, University

of Athens Medical School, “Sotiria”

Hos-pital, Athens (Greece)

Giacomazzi D.

Infectious Diseases Unit, University

Hos-pital of Trieste, Trieste (Italy)

Giomarelli P.

Department of Anaesthesia and Intensive

Care Unit, University of Siena (Italy)

Girardis M.

Anaesthesia and Intensive Care Unit I,

Modena University Hospital and Modena

and Reggio Emilia University (Italy)

Goosen J.

Trauma Unit, Johannesburg Hospital,

Di-vision of Trauma and Critical Care,

De-partment of Surgery, University of the

Witwatersrand, Johannesburg (South

Africa)

Grüne F.

Erasmus MC, Department of

Anaesthesio-logy, Rotterdam (The Netherlands)

Guiotto G.

Emergency Medicine Division, S Paolo

Hospital, Naples (Italy)

Gullo A.

Department of Anaesthesia and Intensive

Care, Postgraduate School of Anaesthesia

and Intensive Care, Catania University

Hospital, Catania (Italy)

Gwinnutt C.L.

Department of Anaesthesia, Salford

Royal Hospitals NHS Trust, Hope

Hospi-tal, Salford (UK)

Haitsma J.J.

Interdepartmental Division of Critical

Care Medicine, University of Toronto, St

Michael’s Hospital, Toronto, Ontario

(Canada)

Hillman K.

Area Critical Care Services, Liverpool

Hospital, Liverpool, NSW (Australia)

Horlocker T.T.

Department of Anesthesiology and pedics, Mayo Clinic College of Medicine,Rochester, Minnesota (USA)

Ortho-Huang C.-H.

Department of Computer Science and gineering, University of Connecticut(USA)

Evan-Lauretta D.

Department of Anaesthesia and IntensiveCare, “Policlinico” University Hospital,Catania (Italy)

Lumb P.D.

Department of Anesthesiology, KeckSchool of Medicine at USC,Los Angeles (USA)

Mandelli A.

Anaesthesia and Intensive Care

Depart-ment, Istituti Clinici di Perfezionamento

– Children’s Hospital V Buzzi, Milan (Italy)

Department of Anaesthesia and Intensive

Care, Postgraduate School of Anaesthesia

and Intensive Care, Catania University

Hospital, Catania (Italy)

Mario F.

Paediatric Department, School of

Medi-cine, University of Padua, Azienda

Ospedaliera Padua (Italy)

Massone M.L.

Department of Anaesthesia and Intensive

Care, G Gaslini Institute Children’s

Hospital, Genoa (Italy)

Mazzon D.

Department of Surgery and Director of

the Intensive Care Unit and

Anaesthesio-logy, Belluno Hospital, Belluno (Italy)

Milic-Emili J.

Meakins-Christie Laboratories, McGill

University, Montreal, Quebec (Canada)

Morales M.M.

Instituto de Biofísica Carlos Chagas Filho,

Federal University of Rio de Janeiro (Brazil)

Morelli L.

Emergency Medicine Division, S Paolo

Hospital, Naples (Italy)

Nolan J.

Department of Anaesthesia and Intensive

Care Medicine, Royal United Hospital,

Bath (UK)

Ori C.

Department of Pharmacology and

Anaesthesiology, University Hospital of

Palazzo M.

Division Critical Care Medicine, mersmith Hospitals NHS Trust, CharingCross Hospital, London (UK)

Ham-Pelosi P.

Department for the Environment, Healthand Safety, University of Insubria –Anaesthesia and Intensive Care Unit B,District Hospital and Macchi Foundation,Varese (Italy)

Perrone L.

2nd Anaesthesia, Intensive Care and dominal Transplantation Unit, NiguardaCa’ Granda Hospital, Milan (Italy)

Ab-Petrs-Silva H.

Instituto de Biofísica Carlos Chagas Filho,Federal University of Rio de Janeiro (Bra-zil)

Plani F.

Trauma Unit, Johannesburg Hospital, vision of Trauma and Critical Care, De-partment of Surgery, University of theWitwatersrand, Johannesburg (SouthAfrica)

Di-Rinaldi S.

Department of Critical Care, Section ofAnaesthesiology and Critical Care, Uni-versity of Florence (Italy)

In-XI

Rizzo G.

Department of Anaesthesia and Intensive

Care, Catania University Hospital,

Catania (Italy)

Rödl S.

Paediatric Intensive Care Unit,

Depart-ment of Paediatrics, Medical University

of Graz (Austria)

Rosano G.

Department of Anaesthesia and Intensive

Care, Catania University Hospital,

Catania (Italy)

Salvo I.

Anaesthesia and Intensive Care

Depart-ment, Istituti Clinici di Perfezionamento

– Children’s Hospital V Buzzi, Milan

(Italy)

Sapienza D.

Department of Anaesthesia and Intensive

Care, Catania University Hospital,

Catania (Italy)

Schiraldi F.

Emergency Medicine Division, S Paolo

Hospital, Naples (Italy)

Scolletta S.

Department of Cardiothoracic

Anaesthe-sia and Intensive Care Unit, University of

Siena (Italy)

Severgnini P.

Department for the Environment, Health

and Safety, University of Insubria –

Anaesthesia and Intensive Care Unit B,

District Hospital and Macchi Foundation,

Varese (Italy)

Sorbello M.

Department of Anaesthesia and Intensive

Care, Catania University Hospital,

Catania (Italy)

Sprung J.

Division of Multispecialty Anesthesia,

Mayo Clinic, Rochester (USA)

Tang W.

Keck School of Medicine, University of

Southern California, Los Angeles, CA (USA)

Trevisanuto D.

Paediatric Department, School of cine, University of Padua, Azienda Ospe-daliera Padua (Italy)

Medi-van Saene H.K.F.

Department of Medical Microbiology,Royal Liverpool University Hospital, Li-verpool (UK)

Vaschetto R.

Interdepartmental Division of CriticalCare Medicine, University of Toronto, St.Michael’s Hospital, Toronto, Ontario (Ca-nada)

Depart-Wolfler A.

Anaesthesia and Intensive Care ment, Istituti Clinici di Perfezionamento– Children’s Hospital V Buzzi, Milan(Italy)

Depart-Zandstra D.F.

Department of Intensive Care Medicine,Onze Lieve Vrouwe Gasthuis, Amsterdam(The Netherlands)

Zhang H.

Interdepartmental Division of CriticalCare Medicine, University of Toronto, St.Michael’s Hospital, Toronto, Ontario(Canada)

XII

Zin W.A.

Laboratory of Respiration Physiology,

Carlos Chagas Filho Institute of

Biophy-sics, Federal University of Rio de Janeiro

List of Abbreviations

DP Driving Pressure

DP/DV Elastance

DPoes Changes in Oesophageal Pressure

DV Change in the Volume

DV/DP Compliance

DV’ Resistance

ACE Angiotensin Converting Enzyme

ACGME Accreditation Council of Graduate Medical Education

ADH Antidiuretic Hormone

AG Anion Gap

AGNB Aerobic Gram-Negative Bacteria

AHA American Heart Association

AHI Apnoea/Hypopnoea Index

Aix Augmentation Index

ALI Acute Lung Injury

ANH Acute Normovolaemic Haemodilution

AOP Apnoea Of Prematurity

API Application Interface

APTT Activated Partial Thromboplastin Time

ARC Australian Resuscitation Council

ARDS Acute Respiratory Distress Syndrome

ARF Acute Renal Failure

AS Arterial Stiffness

ASA American Society of Anesthesiologists

ASK1 Apoptosis-Signalling Kinase 1

ASRA American Society of Regional Anesthesia

Asys Area Under the Systolic Portion of the Pressure Wave

BP Blood Pressure

C(p) Compliance Corrected for Arterial Pressure

CAVH Continuous Arterio-Venous Haemofiltration

CAVHD Continuous Arterio-Venous Haemodiafiltration

CBF Cerebral Blood Flow

CCE Cardiac Cycle Efficiency

CFI Cardiac Function Index

CHDF Continuous Haemodiafiltration

CISV Connecticut Institute for Supercomputing and VisualizationCNS Central Nervous System

CO Cardiac Output

COP Colloid Oncotic Pressure

COPD Chronic Obstructive Pulmonary Disease

CPAP Continuous Positive Airway Pressure

CPFA Coupled Plasmafiltration-Adsorption

CPNBs Continuous Peripheral Nerve Blocks

CPP Coronary Perfusion Pressure

CPR Cardiopulmonary Resuscitation

CRM Crew Resource Management

CRRT Continuous Renal Replacement Therapy

CT Computed Tomography

CVP Central Venous Pressure

CVVH Continuous Veno-Venous Haemofiltration

CVVHD Continuous Veno-Venous Haemodiafiltration

dp/dt Pressure Variations Over Time

DVT Deep Vein Thrombosis

ECF Extracellular Fluids

EELV End Expiratory Lung Volume

EF% Ejection Fraction

EFL Expiratory Flow Limitation

ELAD Extracorporeal Liver Assisted Device

ELBWI Extremely Low Birth Weight Infants

EMS Emergency Medical Services

ER Endoplasmic Reticulum

ERC European Resuscitation Council

ESRD End Stage Renal Disease

EUO Effective Urine Output

XVI

EVLW Extra-Vascular Lung Water

FDA American Food and Drug Administration

FiO2 Fraction of Inspired Oxygen

FOT Forced Oscillation Technique

FRC Functional Residual Capacity

GABA Gamma-Amino Butyric Acid

GEDV Global End-Diastolic Volume

GFR Glomerular Filtration Rate

GIVITI Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva

GP General Practitioner

HD Haemodialysis

HES Hydroxyethyl Starch

HIT Heparin-Induced Thrombocytopenia

HIV Human Immunodeficiency Virus

ICF Intracellular Fluids

ICH Intracerebral Haemorrhage

ICP Intracranial Pressure

ICU Intensive Care Unit

IHCA In-hospital cardiac arrest

IHD Intermittent Haemodialysis

IL-1R Interleukin-1 Receptor

ILCOR International Liaison Committee on Resuscitation

INR International Normalised Ratio

IRAKs IL-1R-Associated Protein Kinases

IRES Internal Ribosomal Entry Sites

ISS Interstitial Space

ITBV Intrathoracic Blood Volume

ITEB Information Technology Engineering Building

IVS Intravascular Space

JTTR Joint Trauma Theatre Registry

KIA Killed In Action

LIP Lower Inflexion Point

LMWH Low-Molecular Weight Heparin

LOD Logistic Organ Dysfunction

LPS Lipopolysaccharide

LV Left Ventricle

MA Metabolic Acidosis

XVII

MAPK Mitogen-Activated Protein Kinase

MARS Molecular Absorbent Recirculating System

MAS Meconium Aspiration Syndrome

MDRD Modification of Diet in Renal Disease

MEFV Maximal Expiratory Flow-Volume

MET Medical Emergency Team

MgSO4 Magnesium Sulphate

MIF Migration Inhibitory Factor

MLAC Minimum Local Anaesthetic ConcentrationMMPs Matrix Metalloproteinases

MO Morbid Obesity

MOCA Maintenance of Continued Accreditation

MODS Multiple Organ Dysfunction Syndrome

MOF Multiple Organ Failure

MOSF Multiple Organ System Failure

MRDH Modified Rapid Deployment Hemostat

MRI Magnetic Resonance Imaging

MRSA Methicillin-Resistant Staphilococcus AureusMSSA Methicillin-Sensitive Staphilococcus AureusMVT Monomorphic Ventricular Tachycardia

NAC N-Acetylcysteine

NEP Negative Expiratory Pressure

NFL Non Flow-Limited

NHS National Health Service

NICE National Institute for Health and Clinical ExcellenceNMDA N-Methyl-D-Aspartatic acid

NPE Neurogenic Pulmonary Oedema

NRCPR National Registry of Cardiopulmonary ResuscitationNRP Neonatal Resuscitation Program

NS Normal Saline

NSG Naso-Gastric Suction

OG Osmolal Gap

OHCA Out-of-Hospital Cardiac Arrest

OPS Orthogonal Polarisation Spectral

OSAS Obstructive Sleep Apnoea Syndromes

P Pressure

PA Pulmonary Artery

PAC Pulmonary Artery Catheter

PAN Polyacrylnitrile

PaO Pressure at the Airway Opening

PaO2 Partial Oxygen Pressure In Arterial Blood

PAOP Pulmonary Artery Occlusion Pressure

XVIII

PAP Plasma Adsorption Perfusion

PARs Proteinase-Activated Receptors

PBEF Pre–B-Cell Colony-Enhancing Factor

PCD Programmed Cell Death

PCM Pulse Contour Method

PCO2 Carbon Dioxide Tension

PCWP Pulmonary Capillary Wedge Pressure

PD Peritoneal Dialysis

PEA Pulseless Electrical Activity

PEEP Positive End-Expiratory Pressure

PEEPi Intrinsic Positive End-Expiratory Pressure

PERK Protein Endoplasmic Reticulum Kinase

pHi Intramucosal pH

PICU Paediatric Intensive Care Units

Poes Oesophageal Pressure

Posm calc Calculated Osmolality

Posm meas Measured Osmolality

Posm Plasma Osmolality

PPCM Peri-Partum Cardiomyopathy

PPM Potentially Pathogenic Micro-organisms

PPV Pulse Pressure Variation

PslCO2 Predictive value of Sublingual PCO2

P-V Pressure-Volume Curve

PVT Polymorphic Ventricular Tachycardia

PWA Pulse Wave Analysis

QOL Quality of Life

RAAS Renin-Aldosterone-Angiotensin System

RAP Right Atrial Pressure

RBC Red Blood Cells

rFVIIa Activated Recombinant Factor VII

RL Ringer’s Lactate

RNS Reactive Nitrogen Species

ROS Reactive Oxygen Species

ROSC Return of Spontaneous Circulation

RRC Residency Review Committee

RRT Renal Replacement Therapy

RVEDV Right Ventricular Enddiastolic Volume

RVP Right Ventricular Pressure

SA Spinal Anaesthesia

SCU Slow Continuous Ultrafiltration

ScvO2 Central Oxygen Venous Saturation

SDD Selective Digestive Decontamination

XIX

SMR Standard Mortality Ratio

SNS Sympathetic Nervous System

SOFA Sequential Organ Failure Assessment

SOP Standard Operating Procedure

SPV Systolic Pressure Variations

SV Stroke Volume

SVR Systemic Vascular Resistance

SVV Stroke Volume Variation

t Time

TBW Total Body Water

TD Thermodilution

TF Tissue Factor

TGF-b Latent Transforming Growth Factor

TIMPs Tissue Inhibitors Of Metalloproteinases

TISS Therapeutic Intervention Scoring System

TLRs Toll-Like Receptors

TPN Total Parenteral Nutrition

TRAF6 TNF Receptor-Associated Factor 6

TRRI-Surg Trauma Readiness and Research Institute for Surgery

UConn University of Connecticut

UIP Upper Inflexion Point

Zao Aortic Impedance

ZEEP Zero End-Expiratory Pressure

XX

ETHICS

Dying in the Intensive Care Unit

K HILLMAN

“- and so drenched in sweat John fought his way to death through tortures indescribable.”

Henry Handel Richardson: The Fortunes of Richard Mahoney.

In 2000 it was reported in Time magazine [1] that while 70% of Americans wanted

to die at home, approximately 75% died in medical institutions and over 30% ofthose spent their last 10 days of life in an intensive care unit (ICU) Other studieshave shown that approximately 50% of all deaths occur in the ICU [2] Approxima-tely 70% of Canadians now die in hospitals [2] Not only is it not what people want,but as a result many of the families have faced financial hardship [3]

We spend about 50% of our health budget on patients who are in their last

6 months of life [4] Given the choice, many of these patients would probably havecheerfully forgone the pain and suffering of major procedures if they had receivedmore balanced information about their care

How did this situation occur? Like many simple questions this one has complexanswers With increasing specialisation in medicine, there has also been fragmen-tation The general practitioner (GP) would have delivered most health care beforethe Second World War; GPs now often serve as the first triage point for seriouslyill patients on their journey into acute hospitals There is pressure from families to

do everything possible even if the family doctor suspects the patient is dying.Moreover, family physicians do not necessarily feel comfortable with dying pa-tients; nor are they logistically able to provide time-consuming care to the dyingpatient at home Because medical advances are reported on a daily basis, the GPdoes not necessarily know of the latest options available for medical care It is easier

to just call an ambulance The dying patient is then triaged in the emergencydepartment at the front door of the hospital Emergency physicians or doctors offirst contact usually see their role as resuscitating patients, not plucking them offthe conveyor belt and letting them die There may be potentially reversible aspects

to their disease which require further tests and interventions

Once in hospital, the patient often comes under the care of a single-organspecialist While these doctors may have great skills in well-defined diseases, theyoften lack the skills and knowledge to understand the multi-system nature ofserious illness They feel out of their depth, and either they refer such patientselectively to intensive care physicians or the patients are picked up by earlywarning systems for the seriously ill, such as the Medical Emergency Team (MET)concept [5, 6]

Chapter 1

The conveyor belt then reaches its final destination, carrying the seriously ill,but often naturally dying, patient from home to the ICU.

The increasing tendency for the dying to be managed in the ICU has manydrivers, including fear of litigation Moreover, hospital specialists do not under-stand the limits of what the ICU can offer and so they often, out of ignorance, referpatients who are thought to be seriously ill to the ICU, whether or not there is anyprospect of appropriate care It is also easier for specialists to avoid difficultconversations with relatives and patients about dying and simply request admis-sion to the ICU

Whilst this is costing society enormous sums through increases in health bills,

it is difficult for politicians and health administrators to restrict intensive careresources because it may result in potentially avoidable deaths and damagingpublicity It is easier to concentrate on easier targets, such as community andpreventable health costs

The problems are just beginning when dying patients are first admitted to theICU Not the least of them is the fact that the diagnosis of dying is difficult to makewith certainty Like death, dying is defined by a medical practitioner, and not bylawyers or ethics committees There will always be uncertainty around dying, andintensive care physicians vary enormously in their practice Withdrawing andwithholding treatment after the diagnosis of dying is made usually results in death,and there is very wide variability in physicians’ willingness to make these decisions,both between different countries and even between intensive medicine specialistswithin the same ICU

Patients likely to benefit from care in the ICU include those with reversible orpotentially reversible conditions; factors such as preceding chronic health status,preceding quality of life, physiological reserve, biological age, severity of the illnessand anticipated disability must be taken into account One of the problems withsuch concepts as frailty and futility is that these are difficult to measure and onlybecome apparent as a result of a patient’s failure to respond to maximum therapy.One approach, therefore, in the face of uncertainty is to challenge the patient’sphysiology We do this when the fluid status of the body is determined or by means

of lung recruitment strategies Often it is difficult to make a diagnosis of dying onadmission to the ICU One acceptable approach is to apply aggressive treatmentfor 24 h and then to rigorously assess the patient’s response If there is substantialimprovement it may be appropriate to continue If the patient is rapidly deteriorat-ing in spite of maximum therapy and the other factors mentioned above are takeninto account it may be reasonable to make a diagnosis of dying

However, it can be frustrating to keep people alive for days or even weeks whilethey slowly fall apart despite maximum medical therapy This can be difficult forhealthcare workers directly involved in patient care as well as for relatives, to saynothing of the suffering endured by patients

Every study shows that most people would not want to endure such an end totheir life

Intensive care has the potential to be able to deliver a death that can be regarded

as ‘‘good’’, as defined by freedom from avoidable distress and suffering for patients,

families and carers, and that is also generally in accord with the patient’s family’swishes and reasonably consistent with clinical, cultural and ethical standards [7].While this sounds attractive it can be difficult to put into practice The so-calledfour principles of medical ethics offer even less They are autonomy, beneficence,nonmaleficence and distributive justice Trying to apply these principles whilemaking decisions about withdrawing and withholding treatment at an individualpatient’s bedside would, in theory, allow for almost any action or justification.How do we make the diagnosis of dying and then make the decision to withholdand withdraw treatment? Dying is now the most common illness in ICUs, with over20% of Americans dying in, or shortly after being in, an ICU [8] Up to 90% ofpatients who now die in our ICUs die as a result of withdrawal of treatment [9].And yet the doctors caring for patients in the ICU are systematically overoptimistic

in their prognoses [10] Nursing staff are often not formally included in thedecision-making process [11, 12] Under 5% of patients dying in the ICU havesufficient mental competence to make their own decisions [13]

Yet surrogates often fail to represent the patient’s wishes In fact, many of thefamilies do not want to be involved in end-of-life decisions [14] and are left withhigh rates of anxiety and depression as a result of being burdened with makingthem [15]

Not surprisingly there is a wide range of end-of-life practices across countriesand individuals [16], with little standardisation

The approach in the United States of America puts an emphasis on the nomy of the patient, with intensive care specialists posing the question “… Whatwould you like us to do?” Posed with this question the answer is often inevitable:

auto-“We would like everything done”, as relatives do not want to be seen to not care

In Australasia and Europe, in contrast, it is more common to put the inevitability

of dying to relatives and highlight the cruelty and futility associated with furthermanagement, implying that this is a medical decision rather than one to burdenrelatives with There is a difference between saying to relatives, “…The chances ofrecovery are slim” and telling them, “…There is a great risk that this person willremain neurologically devastated for the rest of their life” (S Streat, personalcommunication)

At the same time, patients and their families state that their priorities includeadequate pain and symptom control; avoiding inappropriate prolongation ofdying; retaining a sense of control if possible; relieving the burden on the relatives

of patients; and strengthening relationships with loved ones [17]

The principles of palliative care are well defined but apply mainly to patientsdying of cancer These patients are usually alert and co-operative and have months

or even years to live The principles to be applied in palliative care in the ICU arestill being formulated Patients in the ICU are usually unconscious, and the eventprecipitating their admission is often sudden and unexpected We rely heavily onrelatives for information about the patient’s wishes, which may put an unfairburden on them Moreover, community expectations about what modern medicinecan offer are usually unrealistic These can be reinforced by the impressive range

of equipment in the ICU Nevertheless, excellence in end-of-life care is as important

Dying in the Intensive Care Unit 5