Do more in the ICU by doing less, session suggests

Clockwise: Karan Singh, MBBS, FCCP; Mangala Narasimhan, DO, FCCP; Matthew Siuba, DO; Maksim Korotun, DO

Too many critical care clinicians do too much. The typical ICU patient is intubated, has a central line, an arterial line, gets daily chest radiographs, and sometimes blood draws every 2 hours. These routine interventions can harm patients, increase patient pain and discomfort, absorb too many staff hours, and squander scarce resources.

These topics were addressed in a critical care discussion of Masterly Inactivity: The Art and Science of Reducing Unnecessary Interventions in the ICU at CHEST 2020 on Sunday, October 18. The session recordings are available for viewing on the virtual CHEST 2020 meeting platform through January 18, 2021, for registered attendees.

“All of the interventions we do automatically on a daily basis are simply not necessary,” said Mangala Narasimhan, DO, FCCP, senior vice president and director of critical care services at Northwell Health and professor of medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. “Thirty percent of all medical spending is unnecessary and does not add value to care. That is a tremendous amount of money wasted.”

It is also a tremendous amount of unnecessary, uncomfortable, and potentially harmful care.

“Why do we put an arterial line in almost every ICU patient?” asked Karan Singh, MBBS, FCCP, cardiovascular and pulmonary disease specialist at Tristar Greenview Regional Hospital. “We do it because we’ve always done it. That is a flawed paradigm of care.”

Few patients actually need an arterial line because the same information can be obtained from a venous line, Dr. Singh continued. Venous lines mean less discomfort for the patient, less blood loss, and less risk of thrombosis compared to arterial lines.

Too many clinicians and ICUs routinely apply interventions that are unnecessary, painful, harmful, or all three.

“Our efforts are all about the patient,” Maksim Korotun, DO, assistant professor of medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. “Our goal is to spare them interventions that are less likely to be helpful. We don’t want to depersonalize people when they come to the ICU and over-intervening makes that more likely.”

The reasoning behind too many ICU interventions is outdated. Clinicians get ABGs to assess the patient’s overall acid-base status, PCO2 level and trends in ventilator patients. The reality is venous blood gases (VBG) provide the same level of actionable information for the vast majority of patients, Dr. Singh said. 

And while not all VBG machines can do co-oximetry for methemoglobin or show A-a gradients, these values are not necessarily clinically helpful.

“More information is not equal to useful information,” Dr. Singh said.

Too frequent labs and daily chest radiograph are another common source of useless information.

Too many clinicians and ICUs order too many labs, Dr. Narasimhan said, or time labs inappropriately. It is all too easy to check hemoglobin levels before a transfusion when the draw should have been taken after the unit of blood.

And depending on the frequency and amount of blood collected, too many labs can cause iatrogenic anemia. The needed transfusions bring additional risks to patients.

Daily chest radiographs for mechanically ventilated patients are similarly unnecessary, Dr. Narasimhan continued. Studies have found that fewer chest radiographs are not associated with changes in morbidity or mortality. And ultrasound can be more useful than radiographs.

Ultrasound is easier than radiographs to ensure proper placement of an enteral feed tube, she noted, and can be done more quickly with less patient discomfort. Ultrasound is also more useful than radiographs to diagnose pneumothorax and confirm pneumonia.

Central lines are frequently overused in the ICU. Patients who need vasopressors can often be treated more effectively with peripheral lines than central lines, said Matthew Siuba, DO, intensivist at Cleveland Clinic.

Peripheral IV administration of vasoactive agents allows for faster stabilization, he noted, while placing a central line can delay administration of life-sustaining medications.

“Using peripheral IV prevents the need for a central venous catheter without any significant increase in complications,” Dr. Siuba said. “We have seen that extravasation is uncommon and local tissue ischemia can be prevented with a standard protocol.”