Vol. 15 No. 6 November/December 2008

EDITORIAL

MAKING INTENSIVE CARE RELEVANT IN A TIME OF GLOBALIZATION

Intensive care is an extremely expensive specialty, with the cost of an Intensive Care bed estimated at $2,575 per day1. While widely available in developed countries, it is a scarce and sometimes non-existent resource in developing countries. Where it is available it is often restricted to those who can afford to pay. For example, in India and China, which together comprise one third of the world population, the contribution of the government to healthcare costs is relatively small and Intensive Care costs are largely met by individuals. So in a world where more than half of the world’s population live in developing countries and 3 billion people live on under US$2.50 per day, is Intensive Care a largely irrelevant luxury or do we have a role to play?
The idea of “Intensive Care without walls” has gained popularity over recent years with the widespread adoption of Medical Emergency Teams and outreach teams2, based on the reasonable, but unproven, assumption that we are experts in acute care and resuscitation in the broader sense, not just in Intensive Care. It is in this role, as acute care specialists, that I believe we have a role to play – not predominantly as providers but as educators. The Global Healthcare Workforce Alliance3 is currently working to minimize the deficiency of 4.3 million healthcare workers in developing countries. While most of these will be community and mid-level healthcare workers the plan also includes an expansion of education and training of all health workers.
The plan calls for a new curriculum based on the needs of each country rather than a traditional medical education. With a high proportion of deaths in these countries resulting from acute illness or injury, acute care surely should have a place in the curriculum. Undergraduate medical education has traditionally played lip service to acute care4 and it is perhaps not surprising that none of the member organizations of the alliance are devoted to acute care. It is time that we not only redressed this deficiency but work with colleagues in developing countries to develop coordinated structured teaching packages, such as the Primary Trauma Care course5, which are relevant to the acute care needs of developing countries.
Migration to the developed world is one of the underlying causes for the shortfall of healthcare workers in developing countries. For example 25% of doctors and 5% of nurses trained in Africa are working in developed countries. While this may be financially beneficial to developing countries the level of migration may be so high as to cause implosion of the health system. We have therefore a responsibility to ensure that we train enough doctors and nurses to meet our needs. The United States, for example, currently trains 30% too few doctors to meet its own needs and $ 25% of doctors in Canada, New Zealand, USA and UK were trained abroad6.
Of course we should also be supporting the development of Intensive Care outside developed countries but we need to be careful and responsible. Extolling the merits of expensive, unproven technologies (e.g. high volume haemofiltration for sepsis, or ECMO for ARDS) without considering the local healthcare system is unhelpful and irresponsible. For those interested in research, studies of diseases relevant to developing countries would be helpful. In 2007 there were 26,000 cases of dengue haemorrhagic fever in the Americas alone7, yet there are virtually no critical care studies of dengue.
We need to look, not just beyond the walls of our ICUs, but beyond the borders of our countries.

Charles Gomersall FJFICM,
Associate Professor,
Dept of Anaesthesia & Intensive Care,
The Chinese University of Hong Kong,
Shatin, Hong Kong.

References:
1. Stockwell DC, Slonim AD. Intensive care unit costs: To infinity and beyond or not? Crit Care Med, 2008;36:2676-2678
2. DeVita MAM, Bellomo R, Hillman K et al. Findings of the First Consensus Conference on Medical Emergency Teams. Crit Care Med, 2006;34:2463-2478.
3. Global Health Workforce Alliance. http://www.who.int/workforcealliance/en/
4. Shen J, Joynt GM, Critchley LA, Tan IKS, Lee A. Survey of current status of intensive care teaching in English-speaking medical schools. Crit Care Med, 2004;31:293-298.
5. Primary Trauma Care Foundation. http://www.primarytraumacare.org/
6. World Health Organization. The Global Shortage of Health Workers and its Impact. http://www.who.int/mediacentre/factsheets/fs302/en/index.html
7. World Health Organization. Dengue and dengue haemorrhagic fever. http://who.int/mediacentre/factsheets/fs117/en/

Content

CARDIOVASCULAR

The following papers have been extracted and commented upon:

Nichol G, Thomas E, Callaway CW et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008; 300: 1423–1431.

Evidence Level: IV

Sasson S, Hegg AJ, Macy M et al. Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest. JAMA 2008; 300: 1432–1438.

Bright idea

Evidence Level: IV

Douketis J, Cook D, Meade M et al. Prophylaxis against deep vein thrombosis in critically ill patients with severe renal insufficiency with the low-molecular-weight heparin dalteparin. An assessment of safety and pharmacodynamics: the DIRECT study. Arch Intern Med 2008; 168: 1805–1812.

Evidence Level: III

ICM RECOMMENDED REVIEW PAPERS

Kanji S, Stewart R, Fergusson DA, McIntyre L, Turgeon AF, Hébert PC. Treatment of new-onset atrial fibrillation in noncardiac intensive care unit patients: A systematic review of randomized controlled trials. Crit Care Med 2008;36: 1620-1624. 30 references.

Neumar RW, Nolan JP, Adric C et al. Post-cardiac arrest syndrome. Epidemiology, pathophysiology, treatment and prognostication. A consensus statement from the International Liaison Committee on Resuscitation., the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Circulation 2008;118: e-pub ahead of print. 374 references.

White HD, Chew DP. Acute myocardial infarction. Lancet 2008;372:570-584. 149 references.

ETHICS

ICM RECOMMENDED REVIEW PAPERs

Coggon J. Best interests and potential organ donors. BMJ 2008:336:1346-1347. 15 references.

van Bogaert L-J, Dhai A. Ethical challenges of treating the critically ill pregnant patient. Best Practice Clin Obs Gynaecol 2008;22:983-996. 40 references.

GASTROINTESTINAL

The following paper has been extracted and commented upon:

Bee TK, Croce MA, Magnotti LJ et al. Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma 2008;65:337–344.

Could change clinical practice

Evidence Level: II

HEPATOLOGY

The following paper has been extracted and commented upon:

Gonzalez R, Zamora J, Gomez-Camarero J, Molinero L-M, Bañares R, Albillos A. Meta-analysis: combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med. 2008; 149: 109–122.

Evidence Level: I

Top Quality Research

NEUROLOGY

ICM RECOMMENDED REVIEW PAPERS

Park E, Bell JD, Baker AJ. Traumatic brain injury: Can the consequences be stopped? CMAJ 2008;178:1163-1170. 90 references.

Winter B, Pattani H. Spinal cord injury. Anaesth Intens Care 2008;36:401-403. 3 references.

OBSTETRICS

ICM RECOMMENDED REVIEW PAPERS

Price LC, Slack A, Nelson-Piercy C. Aims of obstetric clinical care management. Best Practice Clin Obs Gynaecol 2008;22:757-799. 87 references.

Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008;359:2025-2033. 80 references.

ORGANIZATION

The following paper has been extracted and commented upon:

van der Togt R, van Lieshout EJ, Hensbroek R, Beinat E, Binnekade JM, Bakker PJM. Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment. JAMA 2008;299:2884–2890.

Bright idea

Evidence Level: III

h2>ICM RECOMMENDED REVIEW PAPERS

Devereaux AV, Christian MD, Dichter JR, Geiling JA, Rubinson L. Summary of suggestions from the task force for mass critical care summit, January 26-27, 2007. Chest 2008;133:1S-7S. 13 references.

Leong T-Y, Aronsky D, Shabot MM. Computer-based decision support for critical and emergency care. J Biomed Informatics 2008;41:409-412. 14 references.

PAEDIATRIC

The following paper has been extracted and commented upon:

Bateman ST, Lacroix J, Boven K et all. Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. Am J Respir Crit Care Med 2008; 178: 26–33.

Evidence Level: IV

RENAL

The following paper has been extracted and commented upon:

Liu YL, Prowle J, Licari E, Uchino S, Bellomo R. Changes in blood pressure before the development of nosocomial acute kidney injury. Nephrol Dial Transplant 2008; Sep.3 (epub. ahead of print)

Evidence Level: IV

ICM RECOMMENDED REVIEW PAPER

de Miguel D, Garcia-Suárez. Martin Y, Gil-Fernández, Burgaleta C. Severe acutr renal failure following high-dode methotrexate therapy in adults with haematological malignances: a significant number result from unrecognized co-administration of several drugs. Nephrol Dial Transplant

RESPIRATORY

The following paper has been extracted and commented upon:

Sud S, Sud M, Friedrich JO, Adhikari NKJ. Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. CMAJ 2008; 178: 1153–1161.

Top Quality Research

Evidence Level: I

ICM RECOMMENDED REVIEW PAPERS

Mallick S. Outcome of patients with idiopathic pulmonary fibrosis (IPF) ventilated in intensive care unit. Respiratory Med 2008;102:1355-1359. 36 references.

Soni N, Williams P. Positive pressure ventilation: what is the real cost? Br J Anaesth 2008;101:446-457. 151 references.

Ward NS, Dushay KM. Clinical concise review: Mechanical ventilation of patients with chronic obstructive pulmonary disease. Crit Care Med 2008;36:1614-1619. 61 references.

Baudoin S. Invasive mechanical ventilation. Medicine 2008; 36:250-252. 6 references.

Bolton R, Bleetman A. Non-invasive pressure ventilation and continuous positive pressure ventilation in emergency departments: where are we now? Emerg Med J 2008;25:190-194. 40 references.

SEPSIS

The following papers have been extracted and commented upon:

James MT, Conley J, Tonelli M, Manns BJ, MacRae J, Hemmelgarn BR for the Alberta Kidney Disease Network Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter–related infections. Ann Intern Med. 2008; 148: 596–605.

Top Quality Research

Evidence Level: I

Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol 2008; 29: 593–599.

Evidence Level: III

Trautmann M, Halder S, Hoegel J, Royer H, Haller M. Point-of-use water filtration reduces endemic Pseudomonas aeruginosa infections on a surgical intensive care unit. Am J Infect Control 2008; 36: 421–429.

Bright idea

Evidence Level: III

ICM RECOMMENDED REVIEW PAPERS

Cheng AC, West E, Limmathurotsakul D, Peacock SJ. Strategies to reduce mortality from bacterial sepsis in adults in developing countries. PLoS Medicine 2008;5:e175. 81 references.

Yokoe DS, Mermel LA, Anderson DJ et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S12-S21. 17 references.

Bartlett J. The case for vancomycin as the preferred drug for treatment of Clostridium difficile infection. Clin Infect Dis 2008;46:1489-1492. 35 references.

Monaghan T, Boswell T, Mahida YR. Recent advances in Clostridium difficile-associated disease. Gut 2008;57:850-860. 143 references.

Zingg W, Cartier-Fässler V, Walder B. Central venous catheter-associated infections. Best Practice Res Clin Anaesthesiol 2008;22:407-421. 99 references.

TRAUMA

The following papers have been extracted and commented upon:

Duchesne JC, Schmeig R, Islam S, Olivier J, McSwain N. Selective nonoperative management of low-grade blunt pancreatic injury: are we there yet? J Trauma 2008; 65: 49–53.

Could change clinical practice

Evidence Level: IV

ICM RECOMMENDED REVIEW PAPERS

S

Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med 2008;359:1708-1716. 45 references.

Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med 2008;359:1037-1046. 70 references.

1. Blunt pancreatic injury:
a. Is most commonly associated with direct blow to the epigastrium.
b. Is rarely associated with other injuries.
c. Should be strongly considered in trauma patients with raised amylase at presentation.
d. A paper reviewed in this issue of the Monitor demonstrates that even low grade injuries require operative treatment.

2. Fluconazole:
a. Is more hepatotoxic than voriaconazole.
b. Is not appropriate for the treatment of Candida glabrata infections.
c. Should be given a dose of at least 6-12 mg/kg/day for patients with disseminated candidiasis.
d. A paper reviewed in this issue of the Monitor indicates that empirical fluconazole reduces mortality in critically ill patients at high risk of candida infection.

3. Damage control surgery:
a. Bile or bowel contents in the abdominal drains is an indication for early re-laparotomy.
b. The goals of the ICU phase are correction of hypothermia, acidosis and coagulopathy.
c. Abdominal compartment syndrome is common if the abdomen is closed.
d. A paper reviewed in this issue of the Monitor demonstrates better outcome if temporary closure of the abdomen is achieved using polyglactin mesh.

4. Low molecular weight heparin:
a. Is eliminated by the kidneys.
b. Has bacteriostatic effects in animals.
c. Is less likely to cause type II heparin induced thrombocytopaenia syndrome.
d. A paper reviewed in this issue of the journal indicates that use of dalteparin in patients with severe renal impairment results in an increased incidence of bleeding episodes.

Answers

Answers to questions featured in Intensive Care Monitor Vol. 15 No. 6 November/December 2008:

1. Blunt pancreatic injury: TFFF
2. Fluconazole: FTTF
3. Damage control surgery: TTTF
4. Low molecular weight heparin: TTTF