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).
Consider antibiotic de-escalation daily.
Infection can precipitate a need for intensive care admission and can occur as a complication of an ICU admission. The earliest administration of the most appropriate antibiotic and source control confer mortality benefit. However, antibiotics are also frequently used for the presumptive management of patients with ‘sepsis’ that may later prove to not have an infectious aetiology. In most circumstances, data regarding the appropriate duration of antibiotic administration are very difficult to interpret. In some conditions such as endocarditis or osteomyelitis longer courses of antibiotics have been recommended. However, there is increasing evidence that shorter courses of antibiotics for common infections such as hospital acquired pneumonia do not confer worse outcomes or increased mortality than longer courses. Moreover, shorter courses probably help to prevent the development of antibiotic resistance. In the absence of microbiological evidence of ongoing infection and with an improvement in clinical status, consideration should be given to discontinuing antibiotics at the earliest opportunity possible.
- Garnacho-Montero J, Gutiérrez-Pizarraya A, Escoresca-Ortega A, Fernández-Delgado E, López-Sánchez JM. Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality. Critical Care 2015;19:302
- Kumar, A et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-1596.
- Pugh R, Grant C, Cooke RPD, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database of Systemic Reviews 2015;8.
- Australian Therapeutic Guidelines - Antibiotic, version 15, 2014.
- Sawyer RG, Claridge JA, Nathens AB, Rotstein OD, Duane TM, Evans HL, Cook CH, O’Neill PJ, Mazuski JE, Askari R, Wilson MA. Trial of short-course antimicrobial therapy for intraabdominal infection. New England Journal of Medicine 2015;372(21):1996-2005.
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.