This document discusses perspectives on critical care from both a historical and modern context. It covers the evolution of critical care from its origins in the 1950s to innovations developed during the COVID-19 pandemic. Key topics discussed include the history and development of critical care in India, challenges presented by COVID-19, the advantages and risks of protocolized and evidence-based medicine, economics and standards of critical care quality. Recommendations are made around developing surge capacity, staff protection, admission criteria, and lessons learned on allocating beds during pandemic surges.

1. THE GOOD
THE BAD
AND THE
UGLY:
PERSPECTIVES OF
CRITICAL CARE
Dr Aditya Nath Shukla
Head Critical Care and Emergency Medicine
Regency Hospital Ltd Kanpur

2. • Good: that we all aspire to, all white
and error-free
• Bad: that either doesn't work or
causes more problems than it solves
• Ugly: the hurried hack that fixes the
problem and gets rolled out to meet
time and budget but that no-one is
proud of.

3. • Critical care: history and evolution
• Covid 19 the critical care challenges
• Protocolized care and EBM advantages and risks
• Economics of Critical Care
• Quality of care and standards
• Goals
AREAS COVERED

4. HISTORY OF CRITICAL CARE
• Started in 1952 the polio epidemic of
Denmark
• Bjorn Ibsen first ICU of Europe in 1953
• 1959 in US in University of Southern
California and Pittsburgh

6. CRITICAL CARE IN UTTAR PRADESH
• Little history available in literature
• Mostly as SICU under anaesthesiology
• MICU primarily for coronary care
• Modern MICU started in the decade of 90s
• Rapid growth

9. Recommendations:
• Develop Surge capacity
• Provision for supporting surge
• Develop a system of communication, coordination and
collaboration between different departments and ICU
• Develop and provide for staff protection and motivation,
• Have objective, transparent and ethical triage criteria for
admission

10. COVID-19:THE PANDEMIC

12. INNOVATIONS TO MEET SURGE

13. THE PANDEMIC SURGE: ADMISSION CRITERIA
1. principle of ‘first come, first served’
2. Prioritise saving lives
3. Set an absolute age limit to gain access to intensive care. (proposed both
in Italy and Spain during the peak of COVID pandemic).
4. deciding between two medically similar patients
5. whether to remove a ventilator and give it to another patient (Interestingly
58% of lay participants and 79% of healthcare workers in this study
answered yes)
6. should we prioritise those caring for small children or those with specific
professions such as nurses and doctors

14. THE PANDEMIC SURGE: ADMISSION CRITERIA
• Priority and triage on purely medical grounds, accepting that all humans have
an equal right to be treated if they are critically ill
• Set the principles that needs to be followed, both in times when resources are
available, but in particular when we run out of reserves.
• The public also needs education about what critical care can do and what we
can-not, in order to deal with unrealistic expectations within the population.

15. THE PANDEMIC SURGE: LESSONS LEARNT ON
ALLOCATING BEDS
• Resources are not unlimited,
• Redefine Medical ethics in terms of triage for admission
• Responsibility and expectations of society and
government lie.
• The government and society need to urgently discuss and
even codify the concept of triage being a necessity.

18. • First published in 2001 and updated in
2007 and then in 2020
• 3 levels of ICU suitable to Indian
settings
• Recommendations grouped in
structure, equipment and services of
ICU
• Defined mandatory and desirable
standards of all levels of ICU

19. • Critical care: history and evolution
• Covid 19 the critical care challenges
• Protocolized care and EBM advantages and risks
• Economics of Critical Care
• Quality of care and standards
• Goals
FOCUS

20. EBM AND PROTOCOLS
•Shift towards EBM over last 2 decades
•Feasibility of large RCT in Critically ill patients
•The initial euphoria has not lasted

21. PROTOCOLS: THE GOOD, THE BAD AND THE UGLY
• Protocols are specifics plans for care of patients suffering from similar
conditions. Like practice guidelines, practice standards, clinical pathways
etc
• They specify therapeutic and diagnostic choices that apply to the given
condition.
• Some protocols need to be revised or even discarded with time and
knowledge

22. RSBI PROTOCOL OF WEANING
• In 1991, Yang and Tobini introduced the rapid shallow breathing index
(RSBI),
• Touted as the measurement that best predicted successful extubation in
weaning MV.
• In 1996, Ely et al published the landmark article suggesting that once-
daily, protocolized screening done by non-physicians led to a shorter
duration of MV when compared to usual physician-directed care.

23. RSBI PROTOCOL OF WEANING
Study group
• Ventilated Patients who had
1. PaO2/FiO2 ratio of >200, @ < 5 PEEP,
2. Adequate “cough” on suctioning,
3. Off sedatives and vasopressors
4. RSBI of < 105
• Advanced to a two hour trial of
spontaneous breathing (SBT).
• Control group
• No SBT despite meeting all criteria
• Median duration of MV was 4.5 days
in the intervention arm compared
with 6 days in the control arm.
• Two subsequent confirmatory trials
followed in 1999iii and 2000iv.

24. RSBI PROTOCOL OF WEANING
• In 2004, Krishnan et all published a study showing no benefit to
adding protocol-directed weaning “in a closed ICU with generous
physician staffing and structured rounds”
• Tanios et al then published their article which proved to be final
dagger in the protocol’s heart in 2006, in which they demonstrated
that using the RSBI as a weaning predictor actually prolonged
weaning time.
• >13000 articles on google search, on RSBI as a weaning
predictor with conflicting conclusions

25. EBM & PROTOCOLIZED CARE
• Xigris
• Tight glycaemic control
• Immunotrition
• EGDT
• Crystalloid vs Colloid

26. PROTOCOLIZED CARE
• Effectiveness is based on three parameters (quality, adherence,
postulated effect)
• Successful protocols (Good Protocol, Good Adherence, Desired
Effect)
• Bad or Unsuccessful (Good Protocol, Poor Adherence, No Desired
Effect) or (Bad Protocol, Good Adherence, No Desired Effect)
• UGLY (Bad Protocol, Poor Adherence, No Desired Effect/ worse
effects)

27. PROTOCOLIZED CARE: THE UGLY PART
• Adherence to guidelines and protocols to avoid financial & Legal
repercussions.
• Limits autonomy but enhances accountability
• Failure to adhere to protocols will risk be viewed externally as
failing to employ or execute best practices. ( risk of liability
suits)

28. PROTOCOLIZED CARE: THE UGLY PART
• Murphy’s Law (When plans fail, no matter how completely they had
previously been thought out.)
• Protocols must have intrinsic flexibility such that they guide care but can
accommodate deviation and obstacles.
• Suitable for resource limited units, to ensure quality of care
• Protocols are propagators of mediocrity and suppressor of out of
box thinking, innovation and are fraught with risk of stagnation

29. • Critical care: history and evolution
• Covid 19 the critical care challenges
• Protocolized care and EBM advantages and risks
• Economics of Critical Care
• Quality of care and standards
• Goals
FOCUS

30. ECONOMICS OF CRITICAL CARE: THE UGLY FACE

31. ECONOMICS OF CRITICAL CARE: THE UGLY FACE
• The tribune 2019 nov 26

33. Areas to reduce healthcare cost
• Adherence to HIC practices
• Antimicrobial stewardship
• Judicious use of diagnostic studies

34. • Critical care: history and evolution
• Covid 19 the critical care challenges
• Protocolized care and EBM advantages and risks
• Economics of Critical Care
• Quality of care and standards
• Goals
FOCUS

35. • Rapid expansion in services
• Resource intensive
• High cost of care
• Risk of harm
• Poor quality affects outcomes

36. • Canadian ICU
• 22 indicators for quality
improvement and
assurance
• 6 domains
1. Safety
2. Promptness
3. Effective
4. efficient
5. Patient and staff satisfaction
6. Staff work life

37. • Our experience
• 12 QCI monitored
• Equipment utilization and
breakdown
• HAI
• Weaning failures
• Discharge criteria & LOS
• Complications/ adverse evets
• Staff satisfaction and attrition
• Outcome measures

38. • Critical care: history and evolution
• Covid 19 the critical care challenges
• Protocolized care and EBM advantages and risks
• Economics of Critical Care
•Goal
FOCUS

39. THE UGLY ICU: PATIENT AND FAMILY
PERSPECTIVE
• No comfort of care. ( born of
ignorance/ TINA factor)
• Questionable quality of the services
offered
• Unmet/ fraud claims made vis a vis,
infrastructure, manpower expertise
• Litigations/ dissatisfaction/
violence

40. THE GOOD ICU: FAMILY AND PATIENT
PERSPECTIVE
• I'll sleep better knowing my good
friend is by my side to protect me
(more of a fact) Blondie
• Will have faith in the services
offered because:
1. Level of care constant irrespective of
patient
2. Fully backed claims made vis a vis,
infrastructure, manpower expertise