CCU topics.

1. Critical care: the big and little
picture(s)
Hashim Mehter, MD, MSc.
Pulmonary and Critical Care Medicine
Medicine residency noon conference
May 7, 2019

2. 2013

3. Little picture -> Big picture
 Each decision on rounds -> managing organ
system failures -> integrating each problem/organ
system into the bigger clinical picture
 Bigger clinical picture -> trying to visualize/predict
”arcs”
 ”arc” of critical illness
 impact of critical illness on the “arc” of patient’s life
and quality of life
 Prognostication -> best case scenario, worst case
scenario, likelihoods
 Working to elicit patient values and preferences,
acceptable quality of life -> triangulating this with
clinical picture and prognostication

4. Conceptualizing problems
 Problem-based ICU notes/presentations preferred
 “A: Pulm: stable on current vent therapy”
 does not help anyone understand the problems our patients
have
 leads to missed diagnoses/treatments
 A: Acute resp failure from fluMSSA pneumoniaARDS: initiate
low tidal volume ventilation, conservative fluid strategy
or
A: Septic shock due to MSSA pneumonia and ARDS: wean
norepinephrine, complete 8-day course cefazolin
 Much better

5. Principles of organ system
failure
 Acute respiratory failure / ARDS
 Prevent iatrogenic/ventilator-induced further lung injury and
treat underlying cause. Proactively minimize sedation and
actively pursue ventilator liberation as soon as feasible/safe.
Hope for improvement/healing with time.
 Septic shock
 Control source, abx, judicious early fluid resuscitation,
vasopressor support, treat or supportively manage resultant
organ failures over time. De-resuscitate when appropriate.
 Cardiogenic shock
 Optimize preload and afterload, inotropic support,
sometimes bridging with mechanical support while waiting
for improvement with time (or other interventions, e.g. PCI,
CABG, transplant).
 CNS
 Limit damage (e.g. thrombolysis/clot retrieval in acute
stroke) and hope for the best with time.

7. Management of septic shock
 1995: Antibiotics. Fluids. Vasopressors.
 PLUS: pulmonary artery catheter
 2005: Antibiotics. Fluids. Vasopressors.
 PLUS: activated protein C (Xigris)
 PLUS: “early goal-directed therapy”/Rivers protocol
• Blood and inotropes to increase oxyen-carrying capacity
• Targeting fluid resuscitation to goal CVP – resulted in often-
massive fluid resuscitation
 2015: Antibiotics. Fluids. Vasopressors.
 DON’T do any of the stuff above

8. When less is more
• Lower tidal volume and lower plateau
pressures
• Less blood
• Less invasive hemodynamic monitoring
• Less fluids
• Less insulin and less intensive glycemic
control
• Less antibiotics; de-escalation of empiric
therapy and shorter course
• Less sedation and less benzodiazepines
• Less imaging; no daily CXR
• Less calories and protein; trophic feeds
and early underfeeding appear safe
• Less therapeutic hypothermia
• Less/later renal replacement therapy
• Less talking and more listening in family
meetings
• NO:
• CVP monitoring
• PAC monitoring
• EGDT for sepsis
• Supranormal hemodynamic targets
• Hetastarch
• Early tracheostomy
• Immediate central line for
vasopressors
• HFOV in ARDS
• Steroids in routine mgmt. of septic
shock
• Steroids in routine mgmt. of severe
ARDS
• Activate Protein C (Xigris) for septic
shock

9. Less is more
 “The art of medicine consists of amusing the
patient while nature cures the disease.” – Voltaire
 Makes the tried-and-true evidence-based
interventions we do have that much more
important
 Avoid iatrogenesis
 Unnecessary procedures, polypharmacy, etc.
 Growing recognition that much of the good that we
can do comes from “de-ICU’ing” patients
 ICU liberation initiative / ABCDEF bundle

10. ABCDEF bundle

11. Family engagement
 Family presence (if desired)
 At the bedside (“open or flexible”)
 On rounds
 During resuscitation
 During invasive procedures
 ICU diaries
 Help patient to reconstruct incomplete memories
 Gives family constructive task at time of great anxiety
 Data suggests decreased downstream PTSD for both patient
and family

12. Sepsis survivors
 Compared to case-matched cohorts of other
hospitalized patients, sepsis survivors experience
more:
 Limitation of ADLs
 Cognitive impairment
 Mental health impairment (anxiety, depression, PTSD –
often with accompanying somatic symptoms)
 Recurrent infection/sepsis
 Exacerbation of chronic medical conditions
Prescott et al. JAMA 2018;319(1): 62-75.

13. ARDS survivors
 Long-term neuropsychological
impairment is common at one year
 Depression, PTSD, anxiety
 Impaired memory, verbal fluency, executive
function
 At five years, spirometry/PFTs near-
normal, but:
 Decreased physical function / QOL
 Decreased 6 MWT distance
 Persistent psychological sequelae
Herridge et al NEJM 2011; 364:1293
Mikkelson et al AJRCCM; 185:1307

14. Post-ICU syndrome
 No official definition, but generally agreed that
PICS constitutes new/worsened function in
 Cognitive function – attention/concentration, memory,
mental processing speed, executive function
 Psychiatric function – anxiety, depression, PTSD
 Physical function – poor mobility, compromised ADLs,
compromised lung function in ARDS survivors
 Epidemiology not well-studied, but
 5.7 million annual ICU admissions in the U.S.
 4.8 million will survive the ICU stay
 Estimated that ½ or more will suffer from some
component of PICS
 Risk factors: include delirium, age, mechanical
ventilation, duration of critical illness, specific
diagnoses (ARDS and severe sepsis)

15. Post-ICU syndrome
 Important in the context of downstream care
 Primary care
 Hospital medicine
 What can we do to prevent/mitigate PICS
 DO LESS to patients in the ICU when possible
 Get them out of the ICU sooner
 “Activate” them – get them looking and functioning like
real people again as soon as possible
 Emotionally and psychologically support patients and
their families (this is evidence-based)
 Potential role for multidisciplinary ”post-ICU” clinics (?)

16. Prescottetal.JAMA2018;319(1):62-75.

17. Prognostication in the ICU
 We aren’t great at it
 Mortality vs. other patient-centered outcomes
 Functional independence, neuropsych sequelae
 Predictive scoring systems: APACHE, SAPS,
MPM, SOFA
 Not very good at predicting outcomes for individuals
 Data from clinical trials and retrospective
studies for specific disease cohorts
 e.g. cardiac arrest, ARDS
 again, lacks precision for specific patients
 Clinical experience/intuition (combined with
available data): doesn’t always lend itself well to
numbers

18. Prognostication in the ICU
Anderson et al. Annals ATS, 2015.

19. Prognostication in the ICU
Anderson et al. Annals ATS, 2015.
 Key themes:
 Help families to see prognosis through
education, pictures, radiographs, bedside
explanations
 Convey possibility of poor outcomes early
 Discuss prognosis regularly over the course
of ICU stay
 Numeric estimates may be helpful for
families
 Engage multiple clinical disciplines in
coordinating prognostic information

20. Prognostication in the ICU
Anderson et al. Annals ATS, 2015.

21. End-of-life issues in the ICU
 Family meetings
 Practical guidance and strategy
 Triggers and frequency
 “Substituted judgment”
 Factors associated with conflict
 Approaches to conflict
 Family and care team
 Intra-family
 Within care team
 Practicalities of transitioning to comfort care
 Provider burnout
 Integration of consultative services
 e.g. palliative care, spiritual care

22. EoL issues - background
 22% of all US deaths occur in ICUs
 Most ICU deaths are associated with some
limitation of care
 Most decisions to limit care in the ICU are made
by surrogate decision-makers talking to physicians
with whom they have no previously established
trust relationship
 Inconsistent (at best) use of formal advance
directives
 Families/proxies are asked to make difficult
decisions under exceedingly difficult
circumstances
 “Substituted judgment” Angus et al. Crit Care Med, 2004.
Prendergast et al. Am J Respir Crit Care Med, 1998.

23. EoL issues - background
 7 out of 10 Americans express a desire to die at
home
 Chronically ill patients value:
 Avoiding inappropriate prolongation of dying process
 Symptom management near the end of life
 Importance of optimizing end-of-life care widely
recognized
 Not clear that outcomes are meaningfully improving
 From 2000 to 2009, in-hospital death decreased but ICU
use in the last 30 days of life increased
Pritchard et al J Am Geriatr Soc, 1998.
Gruneir et al. Med Care Res Rev, 2007.
Steinhauser et al. JAMA, 2000.
Singer et al. JAMA, 1999.
Teno et al. JAMA, 2013.

24. The ICU family meeting
 Complex interdisciplinary procedure
 Can help achieve humane and effective care when patients and
families face end-of-life decisions
 Deeply anxious patients and families are:
 thrown into a hospital setting that is often strange
and frightening
 working with unfamiliar healthcare professionals
(your PCP isn’t your intensivist anymore)
 faced emergently with terrible choices
 Difficult decisions and challenging discussions call
upon skilled communication competencies
 Formal training hard to come by, and significant gaps in
communication competencies are common
Billings. J Pal Med, 2011.
Levy et al. Crit care med, 2006.

25. Shared Decision-making
 Spectrum of ways in which physician
conceptualizes their role:
 Parentalism/paternalism: the physician makes the
treatment decision with little input from the patient or
family
 Informed choice: the physician provides all relevant
medical information but withholds his/her opinion and
places responsibility for the decision on the family
 Shared decision-making: the physician and family each
share their opinions and jointly reach a decision
Curtis et al. Chest, 2008.

26.  Shared decision-making often considered the
optimal paradigm, but easier said than done
 Some proxies prefer to make decision without
physician input/opinion (some studies indicate a
substantial minority)
 Some physicians don’t believe in offering an opinion
 Conflict over EoL decision-making is common
• Provider-proxy conflict present in 20-50% of cases
• Significant source of stress and anxiety for both provider
and family
White et al. Crit Care Med, 2010.
Curtis et al. Chest, 2008.
White et al. Am J Respir Crit Care Med, 2009.
Breen et al. J Gen Intern Med, 2001.
Abbott et al. Crit Care Med, 2001.
Shared Decision-making in the ICU

27. Curtis et al. Chest, 2008.

28. Something to think about
Barnato et al. Intensive Care Med, 2012.

29. Something to think about
THEME LOW INTENSITY HIGH INTENSITY
Goals of life-sustaining
treatment
The goal of life-sustaining treatment is a bridge to recovery. It
is a means to an end.
The goal of life-sustaining treatment is meeting narrow
physiologic objectives or averting death in the hospital. It can
be an end in itself.
Determination of "dying"
A patient is "dying" when they have a terminal underlying
condition, such as metastatic cancer, or if they are judged to
have a poor quality of life in the event life-sustaining
treatment is continued
There is conflict and ambivalence about when a patient is
"dying," although all agree that a patient whose vital signs
cannot be maintained despite maximal life-sustaining
treatment is dying.
Harms of commission vs.
ommision
Critical care physicians use concerns about harms of
commission, such as iatrogenic harms, prolonging dying, and
treating a patient against their preferences, to rationalize
limitation of life-sustaining treatment.
Critical care physicians express concerns about these harms of
commission, but these infrequently impact the treatment
plan. Concerns about harms of ommision, such as missing
something treatable or limiting life-sustaining treatment for a
patient who might survive, loom larger.
Physician decision-making
self-efficacy
Critical care physicians have a high degree of self-efficacy for
decision-making regarding life-sustaining treatment. They
view family requests for continued treatment as part of the
normal trajectory.
Critical care physicians externalize the locus of control for
decision-making to patients, families, and specialists who they
believe expect aggressive treatment. They view family
requests for continued treatment as a mandate.
Barnato et al. Intensive Care Med, 2012.

30. Managing that “normal trajectory”
Mehter et al. Annals ATS, 2018;15(2), 241-249.

31. Mehter et al. Annals ATS, 2018;15(2), 241-249.

32. Tending to family

33. Impact on providers

34. Summary
 The ICU is chock full of uncertainty
 Short term prognosis / “arc” of critical illness
 Long-term prognosis
 Patient preferences
 Acceptable quality of life
 All families are different and require thoughtful care in
how they are communicated with and engaged in
decision-making
 Less is more
 Sweat the details
 Think about what you can do to “activate” your patient
 Keep your eye on the big picture as it evolves
 Often, the ICU is for buying time to let everything
sort itself out (with your active help)