College of Intensive Care Medicine of Australia and New Zealand
Recommendations from the College of Intensive Care Medicine of Australia and New Zealand on end-of-life care, invasive devices, anaemia, sedation & antibiotics. The College of Intensive Care Medicine of Australia and New Zealand is the body responsible for intensive care medicine specialist training and education in Australia and New Zealand. The College offers a minimum six year training program, in both general and paediatric intensive care, with a number of assessments, culminating in Fellowship of the College of Intensive Care Medicine (FCICM).
Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
Patients in the intensive care unit often require invasive devices as part of their treatment as well as monitoring of therapy. These lines however are a potential source of healthcare related infections. Preventative ‘bundles’ of care including simple measures such as hand hygiene and aseptic methods of insertion and care of devices have reduced the risk of health care related infections. Infections related to invasive devices are a significant cause of morbidity and mortality. Hence, all invasive devices such as arterial lines, central lines, urinary catheters should be removed as soon as possible.
- 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
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.
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.