What is Critical Care? Key Points & references

      
       

 

          
       

  1. Critical care medicine is the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury (SCCM definition).

  2. Critical care is a maturing specialty whose practitioners are “intensivists” and who practice is moving from consult based “open” units, to multidisciplinary “closed” units.

  3. Critical illness is a very specific series of disease syndromes which arise from an enormous spectrum of causes.

  4. A wide variety of disease processes are treated with a limited number of interventions, in an intensive nursing environment.

  5. It is important to differentiate patients who are in critical care units from those with “critical illness”, which is characterized by acute loss of physiologic reserve.

  6. Critical illness should not be compartmentalized into medical and surgical, the problems experienced by critically ill patients and the treatments given are essentially the same, although the causes may differ.

  7. Critical Care is about medicine, care, compassion and organization.

  8. The best intensive care units are the ones with the most effective management structures.

  9. Your first step to become a critical care practitioner is to understand critical illness.

  10. Critical illness occurs when an injury overwhelms physiologic reserve to the extent that life cannot be sustained without outside intervention.

  11. Physiologic reserve decreases with age and chronic disease

  12. Law of Diminishing Reserve: prolonged critical illness depletes physiologic reserve.

  13. There is no single indicator of reserve, although there are many different clinical and laboratory markers of individual organs’ reserve.

  14. Multi-Organ Dysfunction Syndrome” is the internationally recognized term to describe loss of physiologic reserve and progressive organ injury through failure associated with critical illness.

  15. Outcome prediction models and severity of illness scoring systems use chronic health information and age as indicators of physiologic reserve.

  16. They also use markers of organ dysfunction to quantify how sick the patient is.

  17. The combined score has been used as a method of predicting outcome, but the results are not 100% reliable.

References

  1. Baggs JG Association between nurse-physician collaboration and patient outcomes in three intensive care units - Crit Care Med - 1999 Sep; 27(9): 1991-8

  2. G. J. Becker, G. O. Strauch, and H. J. Saranchak. Outcome and cost of prolonged stay in the surgical intensive care unit. Arch.Surg. 119 (11):1338-1342, 1984.

  3. Bone RC, McElwee NE, Eubanks DH, et al: Analysis of indications for intensive care unit admission. Chest 104:1806-1811, 1993

  4. Brown JJ, Sullivan G: Effect on ICU mortality of a full-time critical care specialist. Chest 1989; 96:127-129

  5. Carlson RW Does a full-time, 24-hour intensivist improve care and efficiency? Crit Care Clin - 1996 Jul; 12(3): 525-51

  6. Carson SS, Stocking C, Podsadecki T, et al: Effects of organizational change in the medical intensive care unit of a teaching hospital: A comparison of `open' and `closed' formats. JAMA 1996; 276:322-328

  7. Cerra FB: Healthcare reform: The role of coordinated critical care. Crit Care Med 21:457-464, 1993

  8. B. Chernow. Variables affecting outcome in critically ill patients. Chest 115 (5 Suppl):71S-76S, 1999.

  9. Cuthbertson DP: Observations on the disturbance of metabolism produced by injury to the limbs. Q J Med 1:233-246, 1932

  10. Dimick JB Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection - Crit Care Med - 01-Apr-2001; 29(4): 753-8

  11. J. Epstein and M. J. Breslow. The stress response of critical illness. Crit Care Clin. 15 (1):17-33, v, 1999.

  12. Goldhill D. R. and A. Sumner. Outcome of intensive care patients in a group of British intensive care units. Crit Care Med. 26 (8):1337-1345, 1998.

  13. Groeger JS, Guntupalli KK, Strosberg M, et al: Descriptive analysis of critical care units in the United States: Patient characteristics and intensive care utilization. Crit Care Med 21:279-291, 1993

  14. Hanson CW Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med - 01-Feb-1999; 27(2): 270-4

  15. Hansen J, Marty B, Barr J, et al: Reduction in drug expenditures by SICU team and SICU pharmacotherapists. Crit Care Med 23(1 suppl):A31, 1995

  16. Kelley MA: Critical Care Medicine--A new specialty? N Engl J Med 1988; 318:1613-1617

  17. W. A. Knaus, E. A. Draper, D. P. Wagner, and J. E. Zimmerman. APACHE II: a severity of disease classification system. Crit Care Med. 13 (10):818-829, 1985.

  18. Knaus WA, Draper EA, Wagner DP, et al: Prognosis in acute organ-system failure. Ann Surg 1985; 202:685-693

  19. Landry D. W., H. R. Levin, E. M. Gallant, R. C. Ashton, Jr., S. Seo, D. D'Alessandro, M. C. Oz, and J. A. Oliver. Vasopressin deficiency contributes to the vasodilation of septic shock. Circulation 95 (5):1122-1125, 1997.

  20. Lanken PN: Critical care medicine at a new crossroads: The intersection of economics and ethics in the intensive care unit. American Journal of Respiratory Critical Care Medicine 149:3-5, 1994

  21. LeGall JR, Lemeshow S, Saulnier F: A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957-2963, 1993

  22. Lemeshow S, Teres D, Klar J, et al: Mortality probability models (MPM II) based on an international cohort of intensive care unit patients. JAMA 270:2478-2486, 1993

  23. Lima C, Levy MN, Levy MM: The impact of an on-site intensivist on patient charges and length of stay in the medical intensive care unit. Crit Care Med 23:A238, 1995

  24. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996; 335(23):1713-1720.

  25. Marini CP, Nathan IM, Ritter G, et al: The impact of full-time surgical intensivists on ICU utilization and mortality. Crit Care Med 23:A235, 1995

  26. J. C. Marshall, D. J. Cook, N. V. Christou, G. R. Bernard, C. L. Sprung, and W. J. Sibbald. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 23 (10):1638-1652, 1995.

  27. Montazeri M, Cook DJ: Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med 22:1044-1048, 1994

  28. Poldermans D, Boersma E, Bax JJ, Thomson IR, van de Ven LL, Blankensteijn JD et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999; 341(24):1789-1794.

  29. Pollack MM, Katz RW, Ruttimann UE, et al: Improving the outcome and efficiency of intensive care: The impact of an intensivist. Crit Care Med 1988; 16:11-17

  30. Pronovost PJ Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery - JAMA - 1999 Apr 14; 281(14): 1310-7 Rafkin H, Wisniewski S, Hoyt J: Multidisciplinary 24-hour critical care services improve outcome in diverse risk categories of patients. Crit Care Med 23:A59, 1995

  31. Reynolds HN, Haupt MT, Thill-Baharozian MC, et al: Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA 1988; 260:3446-3450

  32. E. P. Rivers, M. Gaspari, G. A. Saad, M. Mlynarek, J. Fath, H. M. Horst, and J. Wortsman. Adrenal insufficiency in high-risk surgical ICU patients. Chest 119 (3):889-896, 2001.

  33. L. Rosenberg, T. P. Hofer, R. A. Hayward, C. Strachan, and C. M. Watts. Who bounces back? Physiologic and other predictors of intensive care unit readmission. Crit Care Med. 29 (3):511-518, 2001.

  34. Shortell SM, Zimmerman JE, Rousseau DM, et al: The performance of intensive care units: Does good management make a difference? Med Care 1994; 32:508-525

  35. Stein LI, Watts DT, Howell T: The doctor-nurse game revisited. N Engl J Med 1990; 322:546-549

  36. F. Stuber, M. Petersen, F. Bokelmann, and U. Schade. A genomic polymorphism within the tumor necrosis factor locus influences plasma tumor necrosis factor-alpha concentrations and outcome of patients with severe sepsis. Crit Care Med. 24 (3):381-384, 1996.

  37.  G. H. Van den Berghe. Acute and prolonged critical illness are two distinct neuroendocrine paradigms. Verh.K.Acad.Geneeskd.Belg. 60 (6):487-518, 1998.

  38. J. L. Vincent, A. de Mendonca, F. Cantraine, R. Moreno, J. Takala, P. M. Suter, C. L. Sprung, F. Colardyn, and S. Blecher. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med. 26 (11):1793-1800, 1998.  

         
                   
       

         
     

       
       

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