Facts and fiction in critically ill patients

Facts and fiction in critically ill patients

  • Issue 69

Gernot Marx

Almost two decades ago we entered the door of the 21st century and curiously expected novel therapeutic approaches and milestones for the treatment of critically ill patients. In fact, within the past 10 years the mortality following sepsis and critical illness has been significantly reduced.1 For example, the last decade showed numerous changes in the management of severe sepsis, including the tracking of serum lactate levels, aggressive fluid resuscitation, and prompt initiation of effective antibiotic therapy. While the implementation of the Surviving Sepsis Campaign guidelines and sepsis bundles demonstrated significant benefits and decreased mortality from severe sepsis and septic shock, there is still a considerable gap between new alternative experimental findings, science, and its clinical application.2 In this connection, the evolving understanding of the human immunologic response mechanisms stimulated a rethinking of the inflammatory response in critically ill patients.

For many years the prevailing thought was that the pathophysiology of sepsis, associated with an overwhelming and uncontrolled inflammation, is the major determinant contributing to the development of organ dysfunctions. Therefore multiple agents (e.g., TNF and IL-1 blockers, corticosteroids) targeting inflammation have been tested in large-scale clinical trials. Yet, no agent targeting cytokines or inflammation has hitherto shown benefits and some have caused increased mortality. Subsequently, some investigators have found that inflammation response profiles in septic patients are more complex than originally thought, indicating the need for specific immune modulating strategies instead of generalized anti-inflammatory approaches.3 Besides, the difficulties in translation of new therapeutic approaches from bench to bedside may be due to i) lack of individualized approaches in the treatment of critically ill patients and ii) the fact that knowledge about predictive risk factors, which may help to early identify patients with development of organ dysfunctions and prolonged ICU stay, is still sparse.

In contrast to the hurdles in translation of new specific treatment strategies, technological approaches such as tele-consulting by off-site command centres reached emerging relevance for the adequate treatment of critically ill patients in different hospitals. Tele-ICU consulting provides additional expert critical care medical and nursing services to the medical staff, increases the adherence to international treatment guidelines, and helps to identify early signs of clinical aggravation in a patient’s health status. In this connection, a recent meta-analysis showed a consistent trend supporting the efficacy and effectiveness of Tele-ICU consulting, indicating its potential relevance for future clinical practice, with special interest for hospitals in regions with a limited number of critical care specialists.4

Nevertheless, besides the significant reduction in ICU mortality after sepsis and septic shock, the rethinking of the biological process in the human body and the recent technical progresses in support for the treatment of our ICU patients, we have to increase our attention to the fact that we have tripled the number of patients being sent to rehabilitation settings and it is largely unclear how many of these patients ever returned home. In addition, we have to face the fact that about half of deaths occur in the first year following ICU admission after ICU discharge. Importantly, among those who survive, about 50-70% of patients suffer from sustained cognitive impairment and 60-80% of patients suffer from severe functional impairment with significant effects on patient quality of life and health care related costs.1 These dramatic findings clearly indicate that besides some promising approaches and significant progresses in the acute treatment of our critically ill patients, we have to further increase our efforts to significantly improve patients’ mid- to long-term outcome, with special focus on patients’ quality of life.

More details can be obtained at the Euroanaesthesia Congress, by taking part in the session on Sepsis and Biomarkers, 3 June 2017.

1. Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand. JAMA 2014;311:1308-16.
2. Trzeciak S, Dellinger RP, Abate NL, Cowan RM, Stauss M, et al. Translating research to clinical practice. Chest 2006;129:225–32.
3. Jain M, Chandel NS. Rethinking antioxidants in the intensive care unit. Am J Respir Crit Care Med 2013;188(11):1283-5.
4. Kumar S, Merchant S, Reynolds R. Tele-ICU. Open Med Inform J 2013;23(7):24-9.