Australian and New Zealand Intensive Care Society
Recommendations from the College of Intensive Care Medicine & the Australian and New Zealand Intensive Care Society on end-of-life care, invasive devices, anaemia, sedation & antibiotics. The Australian and New Zealand Intensive Care Society is the leading advocate on all intensive care related matters. ANZICS leads the world in intensive care research through its Clinical Trials Group and patient databases, including the Adult Patient Database, the Paediatric Intensive Care Registry and Critical Care Resources.
2.
Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
The ANZICS Statement on Care and Decision Making at the End of Life for the Critically Ill states that the goal of intensive care is to return patients to a quality of life that is acceptable to them. In order to achieve this goal, it is essential that clinicians explore the values and preferences of each patient. Engaging with patients and their families in the discussions around treatment limitations or withdrawal can improve the quality of dying and reduce family and staff stress and bereavement.
Supporting evidence
- Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis. Infection 2015;43(1):29-36.
- O’Horo J, et. al. Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. Crit Care Med 2014;42:1334-1339.
- Pronovost P, et. al. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM 2006;355:2725-32.
- Trautner BW, Hull RA, Darouiche RO. Prevention of catheter-associated urinary tract infection. Curr Opin Infect Dis 2005;18:37-41.
- The Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010); http://www.nhmrc.gov.au/book/australian-guidelines-prevention-and-control-infection-healthcare-2010/b4-2-2-intravascular-acc
- CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
How this list was made
A working group of interested parties from both CICM and ANZICS was formed to develop a list of 12 items that they believe should be focused on to reduce the number of unnecessary tests and interventions performed in intensive care. All CICM Fellows and ANZICS members were surveyed to develop a consensus view of a final list of five items. There were 6 items clearly favoured and two of these were combined by the working group to develop the final 5 recommendations.
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1
For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
- 2 Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
- 3 Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
- 4 Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
- 5 Consider antibiotic de-escalation daily.