Abstract
The below abstracts were missing from Intensive Care Society State of the Art 2016 Abstracts supplement issue 17:4 of Journal of the Intensive Care Society.
What is the biggest threat to ICU? Australians (and New Zealanders)
Simon Lambden
The residents of Australasia have brought us a number of important cultural and technological innovations but perhaps the most significant thing to come out of the Southern hemisphere in the last 20 years or so is the Australia and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG), so why is the ANZICS CTG the biggest threat to ICU?
The ANZICS CTG first came to our attention with the publication of trials such as the SAFE study in 2004. 1 They have gone on to undertake a series of large-scale randomised controlled trials (RCTs) exploring the impact of therapeutic interventions including fluids, blood sugar control, renal replacement therapy, paracetamol, early goal-directed therapy and many more.2–6 The model for these studies is large-scale, delayed consent, randomised trials in multiple centres, making it possible to recruit a large number of patients quickly. This has been an amazing undertaking and one for which the people involved at all levels should be proud. The scale of these studies has quickly led to their outcomes being enshrined in ICU lore. The problem is that because of their design we risk abandoning therapies that may potentially be valuable in some of the patients that we care for.
By recruiting patients using broad inclusion criteria, beneficial treatment effects in some sub-groups of patients may be lost in the noise of those who are less severely ill. For example in ARISE, 2 only one in five of the patients was receiving any dose of vasopressor, meaning that the sickest population who may benefit from a specific therapeutic strategy were not identified. Secondly, because of the impact and profile of their studies, therapies may be abandoned even though a study has methodological issues. In HEAT, 3 the average temperature difference between acetaminophen and placebo-treated patients was just 0.28°C, making a treatment effect mediated by temperature modification unlikely to be detected. Thirdly, by recruiting a heterogeneous study population, the impact of therapies on specific groups is lost and therapeutic choices affected. SAFE recruited any adult patient who was felt to require fluid resuscitation for ‘for intravascular fluid depletion’, 1 which meant that no difference in primary outcome was seen and 10 years were spent dissecting the meaning of secondary outcomes that affected just a fraction of the total studied population.
In summary, the ANIZCS CTG is in part responsible for bringing ICU research to the fore in recent years. However, the large-scale broad inclusion criterion RCT is no longer the way we should approach our clinical trials. There is increasing evidence that there are sub-populations, or ‘endotypes’ that we can reliably detect who mount differing treatment responses to those of the population as a whole.7–9 By identifying these patients and using adaptive trial designs, we can target therapy towards patients most likely to benefit. There is also recognition that analysing one outcome may not fit all patients recruited into a study and may lead to loss of signal amongst the noise in a heterogeneous trial population. Creating patient-specific outcome measures will allow us to determine the efficacy of therapies in returning patients to their pre-morbid state. 10 Moving forward, we need to take smarter approaches to the design, recruitment and analysis of critical care trials or we risk-abandoning therapies that may save lives.
References
Prognostication in intensive care: Physician foibles, fallacies and predicting the future
Arjun Devanesan
ST3 Intensive Care, The Whittington Hospital, London, UK
Abstract
Decisions made in intensive care often revolve around life and death and as such are usually under intense scrutiny. Choosing to admit a patient to the unit, deny admission, withdraw active treatment and specify ceilings of care are all based on clinically predicting mortality and morbidity and the potential for reversing the offending pathology with intensive treatment. This perpetual need to predict the future, coupled with the many uncertainties about the natural history of any critical illness, has sparked the creation of a plethora of statistically formulated decision aids. The integrity of clinical decision making is now gradually being eroded by increased reliance on statistically generated prognostic scoring systems. We are being increasingly led to believe that all decisions need to be computed and supported by a statistically generated number. The exact meaning of that number is rarely debated. These tools, sometimes called scoring systems or predictive models, are almost universally linear regression models or a variant thereof. They provide comforting numerical answers to sticky questions about prognosis which clinicians can use to reassure themselves that the decisions they are making are the right ones.
However, how (if at all) are these scoring systems actually functioning? Is predicting such an uncertain future even possible? Is it sensible? Arguably clinical scoring systems essentially perform pattern recognition on a large scale and in this sense are no more sophisticated than Neanderthals predicting the changing seasons. Why is it then that clinical scoring systems outperform clinicians in predictive ability in almost every study ever conducted in the subject? Paul Meehl’s extensive and convincing research in the subject would have us believe so anyway. One simple explanation would be that clinician predictions are also predominately driven by pattern recognition. Work on heuristic thinking in clinical decision making (or complex, fast-paced decision making in general) would support this thesis. In that case, it is no wonder that a tool which takes into account thousands of patients worth of data, applied mechanically and with equanimity, would outperform clinicians at pattern recognition. ‘Pattern recognition’ is the operative term, however, because a careful analysis of the standard mode of validation used for these models is in fact simply a glorified test of pattern recognition.
This talk will tackle these questions by examining the problems of clinical prediction in general, faulty logical foundations of prognostication using these scoring systems, the possible reasons for their supposed success and what the role of these scores may be in a rational framework.
Clever medics
Jo Fawkner
Abstract
Historically, intensive care units (ICUs) have been staffed by junior doctors from the Anaesthetic rota, with the odd Respiratory registrar thrown in for good measure. Times have changed, and not for the better. The Faculty of Intensive Care Medicine must answer for their misdeeds. The establishment of the stand-alone training programme and opening of our hallowed ICU doors, to the common riff raff of Medical training has left us simple Anaesthetic trainees with deep feelings of inadequacy. There are now representatives from Emergency Medicine, Respiratory, Cardiology, Renal and Infectious Diseases to name but a few. All sticking in their tuppence worth. Us poor anaesthetists and our airway skills are left out of the party. It’s not fair.
Intensive care ward rounds used to consist of things Anaesthetic trainees understood – ventilator settings, titrating inotropic support, changing lines, etc. We’re good at that!
But now, all manner of weird and wonderful investigations are chirpily suggested by keen bean Medical trainees, fresh from their MRCP exams, who are always on the lookout for the zebras when they hear the sound of hooves. They never fail to impress the Consultant Intensivists (our Consultant Intensivists) with these nuggets of golden information. A conversation ensues about said mysterious disease that rings bells of faint recognition amongst the envious Anaesthetists. Desperately digging in a haze of dissipating Vapouriser gas for the long lost list of 25 causes of Clubbing to be shouted out at random. Unfortunately, our suggestion of decreasing the positive end expiratory pressure, pails into insignificance, leaving us little option but to slope to the back of the ward round huddle.
This barrage of extra tests, however clever, does come at a cost. It is possibly a cost that we can ill afford at these times of austerity, especially when you consider how often a positive result comes back and actually changes management.
I suppose some might argue that training Medics on ICU is beneficial for the management of ward patients. This only serves as a double whammy! We are then asked to review a patient who is acutely unwell on the ward, and they’ve only gone and done everything first. With nothing clever to add, we are left holding a cold unfriendly laryngoscope, and told what to do, when to do it and how high to jump. It somewhat takes away the appearance of our superior knowledge and healing powers.
With the growing number of non-airway trained Medics on ICUs, this also leaves us with the problem of emergency airway management when there is no Anaesthetist resident on duty. Is relying on the on call theatre Anaesthetist, for example, really a safe option? They, after all, may be stuck in theatre, and the loss of airway control in ICU may be catastrophic. However, that does leave the Anaesthetist with the chance to breeze in and with a little luck, ‘save the day’. I think even a clever Medic with their superior knowledge of medicine might be impressed by that.
Somewhere on your ICU is a little room full of sadness. It has far more chairs than ought to be in a room that size and a sofa that is much less comfortable than it looks. In this room nothing good ever happens, because this is where you talk not of successes and recovery, but about complications, about limits, about chances and ultimately about death. When you first speak to a family in that room they often say nothing, too numbed, perhaps, by the hours spent in the limbo of the waiting room alone with their thoughts and last month’s magazines. But if they do speak, it is always to ask a question that is simultaneously incredibly simple and yet impossible to answer: ‘Will they survive?’
I believe our inability to answer this question represents the greatest threat to the future of Intensive Care Medicine, because it shows that we have lost sight of what really matters: saving lives. We have allowed ourselves to be seduced by quality of life scores and an inflated belief in our powers of prognostication, forgetting, perhaps, that a good quality of life is a condition peculiar to the living.
As the NHS faces unprecedented financial pressures and senior managers talk of rationing care, now more than ever we need a clear understanding of who will truly benefit from ‘Expensive Care’. Mortality is the perfect outcome measure to achieve this task; it is objective, it has a clear definition, it applies to all ages and cultures, it is always documented in the notes and, most importantly, it matters to our patients. But we have denied ourselves knowledge of the true incidence of mortality through non-evidence-based refusals of admission and the self-fulfilling prophecy of prognostication. This stops now.
We need to undertake the largest study in the history of our profession and offer our patients a six-month trial of truly unlimited Intensive Care Medicine. During this period, all patients who have the potential to benefit from critical care will be admitted and full active treatment will continue until ICU discharge or death. There will be no ceilings of care and no prognostication. As a child of the nineties, I humbly submit that we name this the 2 Unlimited Study, because ‘no no, no no no no, no no no no, no no there’s no limits [to treatment]!’
There will, of course, be naysayers who will speak darkly of the cost and ethics of such a study. These concerns are easily addressed. The cost of expanding ICU capacity will be amply covered by the Brexit windfall the NHS has repeatedly been promised and the increased provision of postoperative critical care beds will reduce the number of cancelled operations. As for the ethics, this study has the potential to save thousands of lives and absolutely no chance of increasing mortality. As such, undertaking it is not just ethically acceptable, it is a moral imperative.
The Intensive Care Unit – No Place For a Woman?
C S Cattlin
Imperial College Healthcare NHS Trust
Eleanor Roosevelt once said ‘Women are like teabags. You don’t know how strong they are until you put them in hot water’ which is a statement exemplified by dedicating your working life to intensive care medicine (ICM).
Despite a rapidly expanding number of female doctors being produced by medical schools in the UK, intensive care medicine attracts fewer females than most other specialties. This is why female doctors – or more specifically a lack of them – will be the greatest threat to the future of intensive care. 1
Elizabeth Garrett Anderson, the first Englishwoman to become a doctor in 1865, could barely have envisaged what is about to occur in the medical profession. 2 On the cusp of 2017 we are due reach a momentous turning point: it is predicted that there will be more female than male doctors practising medicine in the UK, the number of female doctors having increasing at three times that of their male counterparts since 2010.3,4
So why does the dynamic specialty of intensive care medicine attract so few women into its ranks with only 21% of FICM holders and 35% of intensive care trainees being female? 5 What can we do to attract more women into the hallowed walls of intensive care, this bright and shiny futuristic place that so many of us call our home away from home?
Options include more flexibility and less rigidity in working patterns, greater encouragement of less than full time training, making our specialty more ‘quality of life’ friendly – and these are just the tip of the iceberg…
Other specialities such as anaesthesia have adapted to allow for this and as a result have attracted more female trainees and consultants. Should ICM not adapt and undergo such a glorious revolution as a specialty it risks understaffing, current doctors being overworked, ever decreasing morale and exhaustion leading to increased risks to patient safety. Why not evolve? The possibilities are endless and the benefits reaped by all irrespective of gender.
Intensive care as a specialty: ignore women in the workforce at your peril. After all, as they say, a woman’s place is in the intensive care unit.
References
“Will they survive?”
Tom Pratt
Somewhere on your ICU is a little room full of sadness. It has far more chairs than ought to be in a room that size and a sofa that is much less comfortable than it looks. In this room nothing good ever happens, because this is where you talk not of successes and recovery, but about complications, about limits, about chances and ultimately about death. When you first speak to a family in that room they often say nothing, too numbed, perhaps, by the hours spent in the limbo of the waiting room alone with their thoughts and last month’s magazines. But if they do speak, it is always to ask a question that is simultaneously incredibly simple and yet impossible to answer:
“Will they survive?”
I believe our inability to answer this question represents the greatest threat to the future of Intensive Care Medicine, because it shows that we have lost sight of what really matters; saving lives. We have allowed ourselves to be seduced by quality of life scores and an inflated belief in our powers of prognostication, forgetting, perhaps, that a good quality of life is a condition peculiar to the living.
As the NHS faces unprecedented financial pressures and senior managers talk of rationing care, now more than ever we need a clear understanding of who will truly benefit from ‘Expensive Care’. Mortality is the perfect outcome measure to achieve this task; it is objective, it has a clear definition, it applies to all ages and cultures, it is always documented in the notes, and most importantly it matters to our patients. But we have denied ourselves knowledge of the true incidence of mortality through non-evidence based refusals of admission and the self-fulfilling prophecy of prognostication. This stops now.
We need to undertake the largest study in the history of our profession, and offer our patients a six-month trial of truly unlimited Intensive Care Medicine. During this period, all patients who have the potential to benefit from critical care will be admitted and full active treatment will continue until ICU discharge or death. There will be no ceilings of care and no prognostication. As a child of the Nineties, I humbly submit that we name this the 2 Unlimited Study, because “no no, no no no no, no no no no, no no there’s no limits [to treatment]!”
There will, of course, be naysayers who will speak darkly of the cost and ethics of such a study. These concerns are easily addressed. The cost of expanding ICU capacity will be amply covered by the Brexit windfall the NHS has repeatedly been promised and the increased provision of postoperative critical care beds will reduce the number of cancelled operations. As for the ethics, this study has the potential to save thousands of lives and absolutely no chance of increasing mortality. As such, undertaking it is not just ethically acceptable, it is a moral imperative.