Choosing Wisely in the ICU

It’s Thursday, so it’s clinical blog day.  As you are aware, I just got back from the SCCM Critical Care Congress in San Francisco, and while I’ve said that this Congress left me a bit less excited than they traditionally have there was still some great material to share.

The single item I am the most excited about is the extension of the Choosing Wisely campaign into the ICU setting.  Choosing Wisely is an ABIM initiative designed to encourage discussion between patients and physicians about the necessity of tests.  Because of my life as a medical educator, I also see it as consisting of important things we need to be teaching our learners.  There’s a terrific list for many different areas of medical care of things we probably shouldn’t be doing routinely, all of which are driven by evidence and by the specialty societies in the various fields.  The general surgery list was released as part of the initial group; as someone who hasn’t taken general surgery call in a while, I was delighted to see the Critical Care Societies Collaborative list.  And without further ado, the list with some comments…

1.  Don’t order diagnostic tests at regular intervals (for example, every day), but rather in response to specific clinical questions.  I’m a bit notorious for grilling my residents with the question, “What are you looking for?  And what are you going to do about it?” If the answers are “I’m not sure, and nothing,”  then a test isn’t worth ordering.  Cathy DeAngelis, the former Editor-in-Chief of JAMA uses a phrase that’s less eloquent but equally effective:  “It’s like picking your nose- what are you going to do if you find something?”

2.  Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.  I’m debating between two stories here.  One is that of a self-assured neurosurgery intern who, when I was the burn fellow, made an independent decision early one morning to transfuse a child with a hemoglobin of 8.5.  When I questioned him on it and he told me, “Well, it’s my practice…”  he was cut off promptly.  While there was also a bit of chastising that went on, I promptly referred him to the TRICC trial that’s referenced in last week’s blog.  All of that being said, in burns there is currently a prospective RCT replicating TRICC to see if the rules are the same for us (we were excluded as TRICC patients).  I promise a big, glittery blog post when that study is published.

3.  Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.  That said, if someone is profoundly malnourished and they cannot tolerate enteral feeds, go for it.  Remember, though, if you can feed the gut…you should.

4.  Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.  Because of my anti-benzodiazepine bias, also discussed last week, I would add “Thou shalt not place a patient on a continuous infusion of a benzo for sedation unless you have exhausted all other options.”  We know that “Wake up and breathe” works, both in terms of delirium and in terms of pulmonary complications.

5.  Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.  One of the toughest parts of my job as an intensivist is working with families to make the move from our goals of care being cure to our goals of care being comfort.  Obviously this is the one of the recommendations that requires the most discussion with families, but for those who agree that their family member would not want a prolonged and somewhat terrible ICU course or would not want the functional result likely to come, it’s the most compassionate recommendation.  Palliative care makes a real difference when done well.

Choose wisely, readers, and I would love your thoughts on these recommendations.