Critical Care Medicine Publishes New Guidelines
Three new guidelines have been released recently by the American College of Critical Care Medicine (ACCM), all published in Critical Care Medicine this year. The Society of Critical Care Medicine (SCCM) ensures that top research groups and consortiums are involved in the development of all guidelines, which aim to help critical care professionals provide the best care through evidence-based medicine. The guideline topics – sepsis, end of life and new fever evaluation – will be of interest to a broad spectrum of practitioners, as they address issues tackled every day in the intensive care unit (ICU).
SSC Guidelines for Sepsis
Following on the success of the 2004 version of the guideline (800 Google scholar citations as of October 2007), the first revision of the international guideline for the management of severe sepsis and septic shock, developed through the Surviving Sepsis Campaign (SSC), was published in the January 2008 issue of Critical Care Medicine. The guideline, sponsored by 16 international medical organizations with interest in sepsis, include adult as well as pediatric considerations.
This guideline, revised from 2004, features a new grading system for the SSC recommendations. “This recently developed system not only grades the quality of evidence on a scale from A to D, but more importantly, it also grades the strength of a recommendation as either strong or weak based on multiple factors that are important to a practicing clinician,” explained lead author R. Phillip Dellinger, MD, FCCM. “Quality of evidence, risks, costs and magnitude of effect determine the grade.” The guideline authors worked with Roman Jaeschke, MD, and Gordon Guyatt, MD, of the GRADE classification system for evidence-based medicine to make these updates; both physicians serve as faculty at McMaster University in Ontario, Canada.
Additionally, recent clinical trial data influenced multiple recommendations, including the impact of antibiotics, steroids as well as vasopressin in septic shock, recombinant human activated protein C, the level of glycemic control, and the head of bed elevation in mechanically ventilated patients.
The guideline provides a "best practice" template for the practicing clinician and challenges the practice patterns for physicians and hospitals alike, in ICU and non-ICU settings. The SSC notes that the greatest progress in outcome improvement may come from straightforward education and process changes for those caring for severe sepsis patients in the non-ICU setting and across the spectrum of acute care. Among the numerous recommendations included in the updated guideline are:
• A strong recommendation for antibiotics within one hour after diagnosis of severe sepsis.
• A strong recommendation for early goal-directed resuscitation of septic patients during the first six hours after the recognition of the sepsis-induced tissue hypoperfusion.
• A weak recommendation for use of steroids only in septic shock patients with blood pressure poorly responsive to adequate fluid therapy and vasopressors.
• Usual seven- to 10-day antibiotic therapy guided by clinical response, but with a new emphasis on source control and attention to the balance of risks and benefits of the chosen method
• The equivalency of norepinephrine plus low dose vasopressin with norepinephrine alone to treat septic shock.
• In the care of pediatric severe sepsis, the recommendation that therapeutic end-points from the physical exam be used more often and that dopamine be the first drug of choice for hypotension. Steroid use is recommended only for those children with suspected or proven adrenal insufficiency, and the authors advise against the use of recombinant activated protein C for children.
“The SSC guidelines are the basis for the 11 quality indicators that make up the SSC bundles performance improvement initiative. When these 11 indicators are targeted at hospitals as part of protocolized care, combined with educationand feedback, a change in the management of severe sepsis will occur for the better,” said Dellinger, professor of medicine at Robert Wood Johnson Medical School and director of the medical/surgical ICU at Cooper University Hospital in Camden, New Jersey.
Using this guideline as their basis, the bundles have established a global “best practice” for the management of these severely ill patients. Evidence-based recommendations regarding the acute management of sepsis and septic shock are considered to be among the first steps toward improved outcomes. As of February 2008, more than 14,000 patients in 18 countries had been entered into the SSC database.
End-of-Life Guidelines
A new end-of-life guideline was published in the March 2008 issue of Critical Care Medicine (CCM), building on a previous guideline published in December 2001. “Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine”
encourages all ICU practitioners to become competent in every aspect of end-of-life care, including practical and ethical aspects of withdrawing life-sustaining treatment and the use of sedatives, analgesics, and non-pharmacological approaches to ease suffering during the dying process.
Over the last decade, end-of-life care in the ICU has been the focus of much interest and controversy, with situations such as the Terri Shiavo case grabbing international headlines and increasing awareness about this issue. “We felt that an update was both timely and important given the evolution of the field,” explained lead author Robert D. Truog, MD, FCCM, professor of anesthesia, pediatrics, and medical
ethics at Harvard Medical School, senior associate in critical care medicine at Children's Hospital Boston, and director of the Institute for Professionalism and Ethical Practice. The guideline, which reflects a U.S. perspective, is based on ethical and legal principles and is not derived from empirically based evidence. It offers a comprehensive agenda for improving end-of-life care in the ICU to guide research, quality improvement efforts, and educational curricula.
“Just as patients can and should expect the highest level of competence in critical care providers regarding the technical aspects of ICU care, so should they expect the same level of expertise in all aspects of end-of-life care in the ICU,” said Truog. “This includes the ability to compassionately communicate with patients and families, to have knowledge of the ethical principles that guide this care, and to have expertise in the medications and procedures that ensure the comfort of the patient through the dying process, while also treating the family with dignity and respect.”
The guideline authors focus on several important areas of end-of-life care, including family-centered care strategies that emphasize the importance of the social structure within the ICU. The guideline stresses improved communication with the family, which has been shown to improve patient care and family outcomes, and offers other knowledge unique to the end-of-life experience, such as principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation.
“Several key ethical concepts also play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended versus those that merely are foreseen -- the doctrine of double effect,” said Truog.
Because end-of-life care continues even after the death of the patient, the guideline urges ICUs to develop comprehensive bereavement programs to support families as well as
clinical staff.
New Fever Guidelines
In the April 2008 issue of Critical Care Medicine, “Guidelines for Evaluation of New Fever in Critically Ill Adult Patients: 2008 Update from the American College of Critical Care Medicine and the Infectious Diseases Society of America,” outlines how to assess adult ICU patients who develop new fever without an obvious source, updating a guideline previously published in 1998. “In 10 years, many of the diagnostic modalities we use to evaluate patients with fever have changed,” explained lead author Naomi O’Grady, MD. Eleven experts from the Society of Critical Care Medicine and the Infectious Diseases Society of America worked together to create this most recent guideline from the ACCM.
Because fever can have many infectious and noninfectious etiologies, the guideline authors concluded that a new fever in an ICU patient should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. This cost-conscious approach is designed to determine whether or not infection is present and to prevent additional, unnecessary testing.
“The goal is to continue to reduce variability in care while promoting the rational consumption of resources in an efficient evaluation,” said O’Grady, senior staff physician in the critical care medicine department, clinical center at the National Institutes of Health. “This guideline presumes that any unexplained temperature elevation merits a clinical assessment by a healthcare professional that includes a review of the patient’s history and a focused physical examination before any laboratory tests or imaging procedures are ordered.”
It can be difficult for practitioners to determine if an abnormal temperature has been caused by a physiologic process, a drug or an environmental influence. The authors’ recommendations seek to “provide guidance on what may be a reasonable test to order and bring practitioners up to date on the state of the art and the evidence supporting one type of testing over another.”
Because an accurate temperature reading is crucial, the guideline will include recommendations for the most accurate and reliable methods for measuring temperature. It also will recommend that three to four blood cultures be taken within the first 24 hours of the onset of fever, and detailed protocols are included for how, when, and where to obtain those cultures. “The guidance provided to practitioners within this guideline should ensure that patients get evaluations that are supported by data, which should translate into a high degree of confidence in their diagnoses,” Dr. O’Grady said.
