Page 33 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

2 PART 1: An Overview of the Approach to and Organization of Critical Care

CHAPTER An Approach to Critical Care PROVIDING EXEMPLARY CARE
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1 Jesse B. Hall Clinical excellence is founded in careful history taking, physical exami-
DEVELOP AND TRUST YOUR CLINICAL SKILLS
Gregory A. Schmidt
Lawrence D. H. Wood nation, and laboratory testing. These data serve to raise questions con-
cerning the mechanisms for the patient’s disease, on which a complete
prioritized differential diagnosis is formulated and treatment plan initi-
KEY POINTS ated. The reality, complexity, and limitations apparent daily in the ICU
present several pitfalls on the path to exemplary practice. By its very
• Thoughtful clinical decision making often contributes more to the nature, critical care is exciting and attracts physicians having an inclina-
patient’s outcome than dramatic and innovative interventions or tion toward action. Despite its obvious utility in urgent circumstances,
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cutting-edge technology. this proclivity can replace effective clinical discipline with excessive
• While protocols and checklists inform general care of patient unfocused ICU procedures. This common approach inverts the stable
populations in the ICU, for individual patients it is equally impor- pyramid of bedside skills, placing most attention on the least informa-
tant to formulate clinical hypotheses based on an understanding of tive source of data, while losing the rational foundation for diagnosis
pathophysiology, then test them. and treatment.
• Define therapeutic goals and seek the least intensive intervention ■
that achieves each. FORMULATE CLINICAL HYPOTHESES AND TEST THEM
• Novel treatments require objective clinical trials before they are An associated problem is that ICU procedures become an end in them-
implemented, and traditional therapies require clarification of goals selves rather than a means to answer thoughtful clinical questions. Too
and adverse effects in each patient before their use can be optimized. often these procedures are implemented to provide monitoring, ignoring
• Determine daily whether the appropriate therapeutic goal is treat- the fact that the only alarm resides in the intensivist’s intellect. Students
of critical care benefit from the dictum: “Don’t just do something, stand
ment for cure or treatment for palliation. there.” Take the time to process the gathered data to formulate a work-
• Critical care is invigorated by a scholarly approach, involving ing hypothesis concerning the mechanisms responsible for each patient’s
teaching, learning, and performing research. main problems, so that the next diagnostic or treatment intervention
can best test that possibility. Without this thoughtful clinical decision
making, students of critical care are swept away by the burgeoning
armamentarium of the ICU toward the unproductive subspecialty of
critical care technology. So often in the ICU thoughtful compilation of
the patient’s health evaluation preceding the acute event is more helpful
Intensive care has its roots in the resuscitation of dying patients. than acquiring new data defining the current pathophysiologic state.
Exemplary critical care provides rapid therapeutic responses to failure Accordingly, attention to this search for meaningful collateral history
of vital organ systems, utilizing standardized and effective protocols and the retrieval of prior radiologic studies and laboratory values often
such as advanced cardiac life support and advanced trauma life sup- should precede the next invasive ICU procedure. The next intervention
port. Other critically ill patients in less urgent need of resuscitation should be chosen to test a diagnostic hypothesis formulated by thought-
remain vulnerable to multiple organ system failure, and benefit from ful processing of the available data.
prevention or titrated care of each organ system dysfunction accord- Testing a therapeutic hypothesis requires knowing the goal of the
ing to principles for ultimately reestablishing normal physiology. intervention and titrating the therapy toward that end point. Too often
This critical care tempo differs from the time-honored rounding and clinicians managing initial care employ too little too late during resuscita-
prescription practiced by most internists and primary care physicians. tion. For example, physicians unfamiliar with the pace and treatment of
Furthermore, the critical care physicians providing resuscitation and hypovolemic shock may order a bolus of 250 mL of crystalloid solution
titrated care often have little firsthand familiarity with their patients’ followed by 200 mL/h, while the mean blood pressure rises from 50 to
chronic health history, but extraordinary tools for noninvasive and 60 mm Hg over 2 hours. A far better volume resuscitation protocol targets
invasive description and correction of their current pathophysiology. urgent restoration of a normal blood pressure and perfusion, so a bolus
Though well prepared for providing cure of the acute life-threatening of a liter is given every 10 to 20 minutes, to continue until the blood pres-
problems, the intensivist is frequently tasked with the responsibility sure exceeds 90 mm Hg without inducing pulmonary edema. Similarly
of being the bearer of bad news when recovery is impossible, and the results of recent trials of approaches to treating septic shock are
must regularly use compassionate pastoral skills to help comfort dying consistent with a view that more important than placement of invasive
patients and their significant others, using clinical judgment to help monitoring devices and adhering to complex treatment algorithms is
them decide to forego further life-sustaining treatment. Accordingly, the administration of appropriate antibiotics and adequate fluid volumes
experienced intensivists develop ways to curb their inclination toward promptly after the development of hypotension. Evidence from other
3-5
action in order to minimize complications of critical care, while clinical trials informs us that interventions such as fluid resuscitation
organizing the delivery of critical care to integrate and coordinate the should not be open ended but used only to the point of adequate resusci-
efforts of many team members to help minimize the intrinsic tendency tation, since adverse effects of excessive fluid administration are likely.
6,7
toward fragmented care. In academic critical care units, teaching and This principle of titration of therapy toward a thoughtful end point with-
investigation of critical care are energized by the clinical practice; in out causing common adverse effects is depicted in Figure 1-1.
turn, the practice is informed, animated, and balanced by the informa-
programs. Yet the vast majority of critical care is delivered in commu- ■ LIBERATE FROM INTERVENTIONS SO THERE ARE
tion and environment arising from and around teaching and research
nity-based ICUs not affiliated with universities, where critical care NOT MORE TREATMENTS THAN DIAGNOSES
1,2
physicians rely on their penchant for lifelong learning to update their One of the consequences of protocol-driven resuscitations is that the
knowledge and skills through informed reading and participating in recovered patient now has more treatments than diagnoses. An effective
continuing medical education. These activities provide a means for all approach to the adverse outcome of excess therapeutic interventions
critical care physicians to maintain career-long learning and access to is the mindset that liberates the patient from these potentially harm-
new understandings of the management of critical illness. ful interventions as rapidly as their removal is tolerated. For example,

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