Semin Respir Crit Care Med 2019; 40(05): 569-570
DOI: 10.1055/s-0039-1698401
Preface
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Controversies in Critical Care

Margaret A. Pisani
1   Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
› Author Affiliations
Further Information

Publication History

Publication Date:
11 December 2019 (online)

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Margaret A. Pisani, MD, MPH

In 2015, the intensive care unit (ICU) admission rate was 4,247 per 100,000 person-years and the proportion of hospitalizations that included an ICU admission was 16.3%.[1] Despite the large numbers of patients cared for in ICUs, there has not been a single major advance in critical care since the development of ICUs, but there have been many small incremental changes in safety, quality, and provision of care in this environment. There exist many areas of critical care that are lacking large amounts of data or for which the data are conflicting, and so we have chosen to address these controversial topics in ICU medicine.

In this edition of Seminars in Respiratory and Critical Care Medicine (SRCCM), diverse experts in the field of critical care address the most up-to-date research on topics that are on the forefront of caring for patients in the ICU and offer insights on the state of available data, research, and where the field needs to be advanced in the future. Metabolic issues have been on the forefront of ICU patient care, and the article by Tickoo addresses personalized glycemic control, provides practical advice, discusses the role of feeding, and mobility, and advances the idea of developing more nuanced approaches to glycemic management moving toward a personalized approach. Important to glycemic control is nutrition and Korwin and Honiden discuss the most recent nutrition guidelines. They review the pivotal studies examining whom to feed, when to initiate, and what to feed critically-ill patients. In addition, they discuss the role of feeding on gastrointestinal physiology and maintenance of circadian rhythm. Sepsis is responsible for large amounts of morbidity and mortality worldwide and Moss and Prescott address controversies in sepsis management including timing of antibiotics, role of glucocorticoids, which fluid for resuscitation, the balance between fluids and vasopressors, and clinical trials of novel therapies. Acute kidney injury is a frequent occurrence in the ICU and is associated with increased length of stay and mortality. Iacovella and Sarkar discuss the current controversies in renal replacement therapy (RRT) including modality, timing, and dose of RRT. The data regarding nonrenal indications for dialysis are also presented. Recent research in critical care has focused on pain, delirium, sleep, and circadian biology in the ICU. Several articles in this edition of SRCCM address these important topics. In 2018, new pain, agitation/sedation, delirium, immobility, and sleep disruption (PADIS) clinical practice guidelines were published.[2] The PADIS updates included sections on evidence gaps. Pisani et al address the evidence gaps for pain and delirium, specifically focusing on priorities identified by patients and PADIS experts for their importance in critical care practice where the information published limits of evidence-based decision making. Dorsch et al highlight sleep disturbance and outcomes associated with sleep deprivation in the ICU. In addition, they focus on the many challenges of research in this area and posit strategies for pharmacologic and nonpharmacologic sleep promotion in critical illness. Gao and Knauert provide an overview of circadian biology and discuss the link between circadian and sleep disruption in critical illness. They present the circadian research data in critical illness and highlight interventions aimed at maintaining circadian alignment during an ICU admission. There is emerging research focused on the impact of an ICU admission on both survivors and families. Much of this research has examined functional, cognitive, and emotional outcomes of patients, and the impact on their families and caregivers. Geer et al review the data regarding functional and cognitive outcomes post critical illness. They discuss mechanisms and risk factors for post-ICU functional impairment and review the rehabilitation in the ICU literature. In addition, they present future research directions for early mobilization and maintenance of cognitive and functional status. There have been growing data regarding the impact of critical illness on families and caregivers, and Ludmir and Netzer address the issue of family-centered care in the ICU. They review the symptomology data from studies of families and present the important components of family-centered care, such as including families on daily rounds, frequent family meetings, and the ICU environment. Luetz et al discuss innovative solutions to impact postintensive care unit syndrome (PICS), tying in aspects of environment modification to prevent delirium, improve sleep and circadian rhythm, and allow for mobilization. They present data that examines room design concepts such as light, noise, floor plan, and room arrangement in the ICU. Care of critically-ill patients has always been a source of ethical challenges which will only increase as our technology and ability to prolong life increases. Lee and Ward review ethical challenges in the ICU using a case-based approach and include topics of brain death, unrealistic expectations of treatment, proxy decision making, along with substituted judgement and medical futility. Finally, Samanta and Summers review the advances being made in translational research in critical illness. Specifically examining the characterization of patients with acute respiratory distress syndrome (ARDS) and how improved characterization can lead to a better understanding of pathomechanisms and treatment. The articles included in this edition of SRCCM are intended to update the reader on these important areas of critical care that are currently at the forefront of patient care and research.

 
  • References

  • 1 Weissman GE, Kerlin MP, Yuan Y. , et al. Population trends in intensive care unit admissions in the united states among Medicare beneficiaries, 2006-2015. Ann Intern Med 2018
  • 2 Devlin JW, Skrobik Y, Gélinas C. , et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018; 46 (09) e825-e873