Critical care

Critical care medicine is the "health care provided to a critically ill patient during a medical emergency or crisis". It may be provided in intensive care units, "stepdown" hospital wards, emergency rooms, and in field medicine.

Monitoring the critically ill patient

Several measures are available based on blood gas analysis.

Circulation

Pulmonary artery catheterization

Among patients with acute lung injury, the use of pulmonary artery catheterization (Swan-Ganz catheterization) did not improve outcomes over monitoring with central venous catheterization.

Inferior vena cava ultrasonography

Ultrasonography of the inferior vena cava may help detect low central venous pressure. The caval index is the relative decrease in diameter between expiration and inspiration. If the caval index is 50%, then a central venous pressure of < 8 mm Hg is detected with:

• Sensitivity of 91%
• Specificity of 94%

Respiration and oxygenation

PaO₂/FiO2 ratio (PF ratio)

${P/F\ ratio}=\left({\frac {PaO_{2}}{Fi0_{2}}}\right)\times 100$

An example in a healthy person:

${476}=\left({\frac {100\ mm\ Hg}{21\%}}\right)\times 100$

A higher ratio indicates better gas exchange:

• Normal is 500
• ARDS is < 200

Comparative studies suggest this measure correlates better with pulmonary shunts than does the A-a gradient.

Oxygenation index

$Oxygenation\ index=\left({\frac {mean\ airway\ pressure}{P/F\ ratio}}\right)\times 100$

or

$Oxygenation\ index=\left(mean\ airway\ pressure\times \left({\frac {Fi0_{2}}{PaO_{2}}}\right)\right)\times 100$

A lower oxygenation index indicates better gas exchange. The oxygenation index, which includes the mean airway pressure, may better correlate with intrapulmonary shunting than the PF ratio

Alveolar-arterial oxygen (A-a) gradient (alveolar-arterial oxygen difference - AVO₂D)

${\mbox{A-a gradient}}={PAO_{2}}\ -\ {PaO_{2}}$

${PAO_{2}}={Fi0_{2}}*\left({760-47}\right)\ -\ {\frac {PaCO_{2}}{0.8}}$

• Normal is < 10 mm Hg

The A-a gradient is harder to calculate, but accounts for changes in respiration as measured by the partial pressure of carbon dioxide. However, this calculation relies on the respiratory quotient being constant in the prediction of alveolar CO₂ When compared to the PF ratio, the A-a gradient is found to correlate less well with pulmonary shunting.

Among outpatients with possible pulmonary embolism, the A-a gradient may be a better test.

An online calculator for the A-a gradient is at http://www.mdcalc.com/aagrad.

Tissue perfusion

Central venous oxygen saturation (ScvO₂)

In patients with septic shock, maintaining the central venous oxygen saturation (ScvO₂) > 70% is a health care quality assurance measure for the Institute for Healthcare Improvement. This is measured from the superior vena cava. This is hard to predict by physical examination.

Mixed venous oxygen saturation (SvO₂)

In patients with septic shock, maintaining the mixed venous oxygen saturation (ScvO₂) > 65% is a health care quality assurance measure for the Institute for Healthcare Improvement that is an alternative to the central venous oxygen saturation. This is measured from a pulmonary artery catheter. This is hard to predict by physical examination.

The mixed venous pressure may be lower than the central venous pressure due to mixing with blood from the splanchnic circulation or carotid sinuses that has lower oxygen content.

Tissue oxygen saturation (StO₂)

Tissue oxygen saturation (StO₂) at the thenar eminence may be an alternative, non-invasive measurement.

Lactate clearance

Maintaining lactate clearance about 10% may be an easier alternative than invasive measurements of oxygenation according to a randomized controlled trial by EMShockNet.

${\text{Lactate clearance}}=\left({\frac {lactate_{initial}-lactate_{two\ hours}}{lactate_{initial}}}\right)\times 100$

Capnography

Capnography, which is "continuous recording of the carbon dioxide content of expired air," may detect respiratory depression before hypoxemia occurs. Proposed criteria for respiratory depression are:

• End tidal CO₂ (ETCO₂) level 50 mm Hg
• ETCO₂ change from baseline of 10%
• Loss of waveform for 15 seconds

Real time glucose monitoring

Real-time glucose monitoring does not clearly help control the blood glucose level.

Treatments provided in the intensive care unit

Goal-directed resuscitation

Protocols for the resuscitation of septic shock are:

1. "Isotonic crystalloid was administered in boluses to achieve a central venous pressure of 8 mm Hg or higher"
2. "Mean arterial pressure goal of 65 mm Hg or higher, if not achieved with fluid administration, was targeted by initiating and titrating vasopressors (dopamine or norepinephrine)" or goal of 65 mm Hg to 90 mm Hg
3. If ScvO₂ < 70% or lactate clearance < 10%

• If hematocrit is < 30%, packed red blood cells were transfused
• If hematocrit is > 30%, cardiotonic agents such as dobutamine

Circulatory support

Goal-directed resuscitation has been developed and so far studies for the resuscitation of septic shock:

1. "Isotonic crystalloid was administered in boluses to achieve a central venous pressure of 8 mm Hg or higher"
2. "Mean arterial pressure goal of 65 mm Hg or higher, if not achieved with fluid administration, was targeted by initiating and titrating vasopressors (dopamine or norepinephrine)" or goal of 65 mm Hg to 90 mm Hg
3. If ScvO₂ < 70% or lactate clearance < 10%

• If hematocrit is < 30%, packed red blood cells were transfused
• If hematocrit is > 30%, cardiotonic agents such as dobutamine

Surgical and trauma critical care

The standard of care for fluid replacement after traumatic injury continues to evolve. Permissive hypotension is increasingly preferred in most situations: giving enough fluid to return the systolic blood pressure to approximately 100mm, but not to return it to normal. Raising the pressure to normal levels may also raise the pressure enough to disrupt clots and restart hemorrhaging.

Routine use of vasopressors in trauma uncomplicated by disease is discouraged; a surgical maxim is that the treatment for traumatic hypotension is surgery, not drugs.

An important exception to permissive hypotension is the field management of crush injury. In this case, fluid overload, as well as alkalinization, is necessary to protect the kidneys and other organs from the rush of muscle breakdown products when the flow-occluding pressure of a heavy object is removed.

Complications

Abdominal compartment syndrome

Abdominal compartment syndrome is associated with increased mortality.

Medical error

Examining errors in administration of parenteral medications, a study found:

• 74 errors per 100 patient-days
• Independent risk factors were:
  • Patient complexity as measured by
    • number of organ failures
    • number of parenteral administrations
  • Work load as measured by
    • Larger intensive care unit
    • Increased ratio of patient turnover to the size of the unit
    • Number of patients per nurse
    • Occupancy rate of the unit

Preventing complications in the critically ill patient

Delirium

Antipsychotic agents to reduce the number of days mechanically ventilated patients were alive without delirium

Drug	Number of days
Haloperidol	14.0
Ziprasidone	15.0
Placebo	12.5
P = 0.66

Antipsychotic agents, in a small study, found that an average of 15 mgs per day of haloperidol and 113 mg per day of ziprasidone increased akathisia (see table for benefits which did not have statistical significance).

Glucose control

Two clinical practice guidelines are available for patients with ; however, both of these guidelines were developed without broad representation of stakeholders. This may lead to overly aggressive clinical recommendations. In addition, these guidelines were published before the two recent negative trials.

The American Association of Clinical Endocrinologists (AACE) recommends the following target blood glucose levels:

• "Critically ill patients, between 80 to 110 mg/dL (grade A recommendation)"

The American Diabetes Association (ADA) states

• "Critically ill patients: blood glucose levels should be kept as close to 110 mg/dl (6.1 mmol/l) as possible and generally <140 mg/dl (7.8 mmol/l). (A) These patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia. (E)"

Evidence

Randomized controlled trials of tight glucose control in the critical care and perioperative care settings have produced mixed results. See Table.

Meta-analyses of these trials exist:

• Meta-analysis in 2011 of 21 trials was negative.
• Meta-analysis in 2010 of 7 trials was negative.
• Meta-analysis in 2009 of 26 trials was negative.
• Meta-analysis in 2009 of 29 trials was negative.

Selected randomized controlled trials of glucose control in critical care

Trial	Patients	Intervention	Comparison	Outcomes	Results		Authors' conclusions
					Intensive control	Control group
COIITSS Study 2010	509 adults with septic shock	Insulin targeting serum glucose of 80 to 110 mg/dl	2004 Surviving Sepsis Campaign guidelines	In-hospital mortality	45.9% *	42.9%	"intensive insulin therapy did not improve in-hospital mortality "
NICE-SUGAR 2009	6104 patients in medical and surgical ICU	Insulin drip targeting serum glucose of 81 to 108 mg/dl	Insulin drip targeting serum glucose of 144 - 180 mg/dl	Mortality at 90 days	27.5% *	24.9%	"intensive glucose control increased mortality among adults in the ICU"
Arabi et al 2008	523 patients in medical and surgical ICU	Insulin drip targeting serum glucose of 80 to 110 mg/dl	Insulin drip targeting serum glucose of 180 to 200 mg/dl	Mortality in the intensive care unit	13.5%	17.1	"Intensive insulin therapy was not associated with improved survival...and was associated with increased occurrence of hypoglycemia"
SepNet 2008	537 patients with severe sepsis	Insulin drip if needed to target serum glucose of 80 to 110 mg/dl	Insulin drip if needed to target serum glucose of < 200 mg/dl	Mortality in the intensive care unit	24.7%	26%	"intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events"
Van den Berghe 2006	1200 patients in medical ICU	Insulin drip targeting serum glucose of 80 to 110 mg/dl	Insulin drip targeting serum glucose of 180 to 200 mg/dl	Hospital mortality	37.3%	40%	"Intensive insulin therapy significantly reduced morbidity but not mortality"
Van den Berghe 2001	1548 patients in surgical ICU	Insulin drip targeting serum glucose of 80 to 110 mg/dl	Insulin drip targeting serum glucose of 180 to 200 mg/dl	Mortality in the intensive care unit	4.6% *	8%	"Intensive insulin therapy...reduces morbidity and mortality"
Notes: * Significantly different from the control group.

Two of the trials in the Table suggested benefit (see green cells):

• Van den Berghe 2006. Although this trial concluded "intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. Although the risk of subsequent death and disease was reduced in patients treated for three or more days" the trial stated "these patients could not be identified before therapy."
• Van den Berghe 2002. This trial has been criticized for the following reasons:
  

1. "The trial was stopped early for an unexpectedly large treatment effect, which can overestimate the efficacy of treatment or result in a false-positive finding;"
2. "The relative reduction in mortality for a decrease of 50 mg/dL in morning glucose levels seems biologically implausible and exceeds that for any other intervention in critically ill patients;"
3. "The mortality rate in the control group was much higher than that noted in tertiary care medical centers in the United States. On admission to the ICU, all patients received 200 to 300 g/d of intravenous dextrose followed by enteral or parenteral nutrition, an unusual practice considering the deleterious effects of parenteral nutrition; at least in part, the difference in outcomes between the 2 arms in this study might have reflected the harm of maintaining the control group as hyperglycemic rather than the benefit of strict glucose control in the intervention group."

Tight control may protect renal function.

Regarding intraoperative control of glucose, a randomized controlled trial concluded "the increased incidence of death and stroke in the intensive treatment group raises concern about routine implementation of this intervention."

Preventing anemia

Blood transfusion

Clinical practice guidelines

Clinical practice guidelines by the Eastern Association for Surgery of Trauma and the American College of Critical Care Medicine include blood transfusions recommendations for:

1. "patients with evidence of hemorrhagic shock"
2. "patients with evidence of acute hemorrhage and hemodynamic instability or inadequate" oxygenation
3. "A “restrictive” strategy of RBC transfusion (transfuse when Hb < 7 g/dL) is as effective as a 'liberal' transfusion strategy (transfusion when Hb < 10 g/dL) in critically ill patients with hemodynamically stable anemia, except possibly in patients with acute myocardial ischemia."
4. "The use of only Hb level as a 'trigger' for transfusion should be avoided"
5. "In the absence of acute hemorrhage, RBC transfusion should be given as single units"
6. "Consider transfusion if Hb is <7 g/dL in critically ill patients requiring mechanical ventilation"
7. "Consider transfusion if Hb is <7 g/dL in resuscitated critically ill trauma patients"
8. "Consider transfusion if Hb is <7 g/dL in critically ill patients with stable cardiac disease"
9. "RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients."
10. "RBC transfusion may be beneficial in patients with acute coronary syndromes (ACS) who are anemic (Hb < 8 g/dL) on hospital admission"
11. "The transfusion needs for each septic patient must be assessed individually because optimal transfusion triggers in sepsis patients are not known and there is no clear evidence that blood transfusion increases tissue oxygenation"
12. "All efforts should be initiated to avoid RBC transfusion in patients at risk for ALI and ARDS after completion of resuscitation."

Trials

There may not be a meaningful difference in outcomes between transfusing blood to maintain a hemoglobin > 7.0 g/dl versus a hemoglobin > 10.0 g/dl.

Erythropoietin

A randomized controlled trial reported "epoetin alfa does not reduce the incidence of red-cell transfusion among critically ill patients, but it may reduce mortality in patients with trauma. Treatment with epoetin alfa is associated with an increase in the incidence of thrombotic events."

Selective gastrointestinal decontamination

Systematic reviews conclude that selective decontamination of the digestive tract may reduce morbidity in critically ill patients although some randomized controlled trials have and others have not found benefit.

Preventing posttraumatic stress disorder

Light sedation (patient awake and cooperative) may be more effective than deep sedation (patient asleep, awakening upon physical stimulation).

Medical error in the intensive care

Regarding overlooked diagnosis among patients receiving artificial respiration in the intensive care, an autopsy study concluded "abdominal pathologic conditions--abscesses, bowel perforations, or infarction--were as frequent as pulmonary emboli as a cause of class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued."

Predicting outcomes of adult patients

Although there is much research into prognosing patients in intensive care, patients are not very confident in thei accuracy of prognoses.

Apache II score

The APACHE II is available at http://www.sfar.org/scores2/apache22.html.

SAPS II

• SAPS II
• SAPS II (expanded)

CIS

The cellular injury score (CIS) can describe multiple organ dysfunction syndrome.

FOUR

The FOUR (Full Outline of UnResponsiveness) score may be better than the Glasgow Coma Scale (GCS) in prognosticating patients in coma. The FOUR Score tests:

• eye response
• motor response
• brainstem reflexes
• respiration pattern

SOFA

The Sepsis-related Organ Failure Assessment (SOFA) score can describe multiple organ dysfunction syndrome.