“Less Is More”: The New Paradigm in Critical Care




(1)
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA

 




Keywords
HarmLess is moreNew paradigmCritical care


The art of medicine consists of amusing the patient while nature cures the disease

Voltaire, French writer and historian (1694–1778).


What appears to be the world’s first ICU was established at the Municipal Hospital of Copenhagen in December of 1953 by the Danish anesthesiologist Bjorn Ibsen during the polio epidemic of 1952–1953 [1]. The first patient admitted to the unit was a 43 year old man who had unsuccessfully attempted to hang himself. The patient had a tracheotomy performed and received manual positive pressure ventilation with 60 % oxygen in N2O [2]. The first physician staffed ICU’s in the US were developed in 1958 by Max Harry Weil and Herbert Shubin at the Los Angles County General Hospital and by Peter Safar in Baltimore [3, 4]. The introduction of the pulmonary artery catheter (PAC) in the early 1970s by Swan and colleagues became the monitoring tool that defined critical care medicine for the next four decades [5, 6]. The PAC became synonymous with critical care medicine. The era of the PAC resulted in a style of medicine that can best be characterized as aggressive. If some care is good, more care is even better. However almost all medical interventions be they invasive procedures, diagnostic tests, imaging studies, mechanical ventilation, surgery or drugs have some risk of adverse effects [7]. In some cases, these harms outweigh the benefits. This may be particularly so in ICU patients who are highly vulnerable and at an increased risk of iatrogenic complications [8]. Beginning in 1996 the safety and effectiveness of the PAC came into question [9]. Subsequent studies demonstrated that the PAC provided misleading (“physiologic variables”) that could lead to inappropriate therapeutic interventions and that the use of the PAC did not improve patient outcome [1012]. The PAC has now all but been abandoned [13]. In 2000 the ARDSnet group published their now landmark study which demonstrated that mechanical ventilation with low tidal volume of 6 mL/kg/IBW improved patient outcome as compared to the standard approach (12 mL/kg/IBW) [14]. The last decade has witnessed a slew of studies that have challenged conventional wisdom and which have led to a gentler, less invasive approach to the critically ill patient… this has led to the paradigm that “Less may be More” (see list below) [7, 8]. We now realize that our goal as intensivists is too be supportive and allow the body to heal itself while at the same time limiting the harm we cause with are arsenal of therapeutic and diagnostic weapons.

Interventions for which less has been shown to be associated with better outcomes:



  • Lower tidal volume and lower plateau pressures [14]


  • Less blood [15, 16]


  • Less invasive hemodynamic monitoring [13, 17]


  • Lees fluids [1820]


  • Less insulin and less intensive glycemic control [21]


  • Less antibiotics; de-escalation of empiric therapy and shorter course [2224]


  • Less sedation and less benzodiazepines [2527]


  • Less corticosteroids; 200 mg hydrocortisone (equ) daily for sepsis and COPD [2831]


  • Less CXR; no daily CXR [32, 33]


  • Less oxygen; hyperoxia kills (COPD) and damages the brain and lungs [3443]


  • Less calories and protein; trophic feeds may be safe; less protein = less muscle breakdown [44, 45]


  • Less antiarrhythmics; no prophylactic lidocaine in AMI [46]


  • Less stress ulcer prophylaxis (=less C. diff. and less HAP) [47, 48]


  • Less intense renal replacement therapy [4952]


  • Less blood pressure control (in ischemic stroke) [53, 54]


  • NO dopamine [5557]


  • NO “supranormal” hemodynamic targets [58, 59]


  • NO TPN [60, 61]


  • NO diuretics for acute renal failure [62]


  • NO hetastarch [63, 64]


  • NO Activated Protein C [65]


  • NO MRSA/MDRO screening and protective isolation [6668]


  • NO therapeutic hypothermia [69, 70]


References



1.

Berthelsen PG, Cronqvist M. The first intensive care unit in the world: Copenhagen 1953. Acta Anaesthesiol Scand. 2003;47:1190–5.PubMedCrossRef


2.

Long DM. A century of change in neurosurgery at Johns Hopkins: 1889-1989. J Neurosurg. 1989;71:635–38.PubMedCrossRef


3.

Weil MH, Shoemaker WC. Pioneering contributions of Peter Safar to intensive care and the founding of the Society of Critical Care Medicine. Crit Care Med. 2004;32:S8–10.PubMedCrossRef


4.

Safar P, Dekornfeld TJ, Pearson JW, et al. The intensive care unit. A three year experience at Baltimore city hospitals. Anaesthesia. 1961;16:275–84.PubMedCrossRef


5.

Ganz W, Donosco R, Marcus HS, et al. A new technique for measurment of cardiac output by thermodilution in man. Am J Cardiol. 1971;27:392–6.PubMedCrossRef


6.

Swan HJ, Ganz W, Forrester J, et al. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med. 1970;283:447–51.PubMedCrossRef


7.

Grady D, Redberg RF. Less is more: how less health care can result in better health. Arch Intern Med. 2010;170:749–50.PubMedCrossRef


8.

Knox M, Pickkers P. “Less is More” in critically ill patients. Not too intensive. JAMA Intern Med. 2013;173:1369–72.CrossRef


9.

Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA. 1996;276:889–97.PubMedCrossRef


10.

Marik PE, Baram M, Vahid B. Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134:172–8.PubMedCrossRef


11.

Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet. 2005;366:472–7.PubMedCrossRef


12.

Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14.PubMedCrossRef


13.

Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care. 2013;3:38.PubMedCentralPubMedCrossRef


14.

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:301–8.


15.

Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127:124–31.PubMedCrossRef


16.

Marik PE, Corwin HL. Efficacy of RBC transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008;36:2667–74.PubMedCrossRef

Oct 12, 2016 | Posted by in CRITICAL CARE | Comments Off on “Less Is More”: The New Paradigm in Critical Care

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