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).
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.
Critically ill patients requiring mechanical ventilation are frequently treated with sedatives and analgesics, to treat pain, anxiety, dyspnoea and reduce tissue oxygen consumption. However prolonged or excessive sedation can be associated with delirium, critical illness weakness, prolonged ventilation and length of stay. Protocol-based approaches to limit deep sedation, by explicating titrating the sedation to a sedation goal, and daily interruptions of sedation, have been shown to improve patient outcomes, including a reduction in mortality. Exceptions to the daily sedation holiday are for patients requiring muscle paralysis, who should not be woken until the paralytic agent has worn off.
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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.