Overall patient management
These critically ill patients require multidisciplinary care with:
• Intensive skilled nursing care (patient/nurse ratio 1:1).
• Regular physiotherapy.
• Careful management of pain and distress with analgesics and sedation as necessary.
• Constant reassurance and support. Critically ill patients easily become disorientated and psychologically disturbed.
• Nutritional support. Enteral nutrition should always be used if possible.
• H2-receptor antagonists or sucralfate (to prevent stress-induced ulceration). They are generally used, but are probably unnecessary in the fed patient.
• TED stockings and subcutaneous heparin to prevent venous thrombosis.
• Care of the mouth, prevention of constipation and of pressure sores.
RESULTS, COSTS AND PATIENT SELECTION
For many critically ill patients, intensive care is undoubtedly life-saving and resumption of a normal life-style is to be expected.
In the most seriously ill patients, however, immediate mortality rates are high, a significant number die soon after discharge from the intensive care unit, and the quality of life for some of those who do survive may be poor. Moreover, intensive care is expensive, particularly for those with the worst prognosis.
Inappropriate use of intensive care facilities has other implications. The patient may experience unnecessary suffering and loss of dignity, while relatives may also have to endure considerable emotional pressures. In some cases treatment may simply prolong the process of dying, or sustain life of dubious quality, and in others the risks of interventions may outweigh the potential benefits. Both for a humane approach to the management of critically ill patients and to ensure that limited resources are used appropriately, it is therefore important to avoid admitting patients who cannot benefit from intensive care and to limit further aggressive therapy when the prognosis is clearly hopeless.
Currently decisions to limit therapy, or not to resuscitate in the event of cardiorespiratory arrest, are made jointly by the medical staff of the unit, the primary physician or surgeon and the nurses, normally in consultation with the patient’s family.
A variety of scoring systems have been developed that canbe used to evaluate the severity of a patient’s illness. These have included an assessment of the severity of the acute disturbance of physiological function (acute physiology, age, chronic health evaluation-APACHE) and a measure of the therapeutic effort expended on a patient (therapeutic intervention scoring system-TISS). Other systems have been designed for particular categories of patient (e.g. the injury severity score for trauma victims). The APACHE score is widely applicable and has been extensively validated. It can accurately quantify the severity of illness and predict the overall mortality for large groups of critically ill patients, and is therefore useful when auditing a unit’s clinical activity, for comparing results nationally or internationally and as a means of characterizing groups of patients in clinical studies. Although the APACHE methodology can also be used to estimate individual risks of mortality, no scoring system has yet been devised that can predict with certainty the outcome in an individual patient; they must not, therefore, be used in isolation as a basis for limiting or discontinuing treatment.
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