Less is More: Ten Situations Where Doing Less Yields Better Results

For decades, the approach to patient management in the Intensive Care Unit (ICU) has been to perform a large number of interventions in critically ill patients, many of which are based on clinical judgment and the pathophysiology of diseases. However, the evidence for such practices often does not support them. We present 10 common clinical situations in which doing more could be associated with a higher risk of worse outcomes.

Some of the most common interventions in the ICU may be associated with poor outcomes. We present ten situations in which doing less is better for the critically ill patient.

Intravenous (IV) fluid therapy is the main treatment for patients with hypovolemia, commonly due to blood loss or dehydration. However, it has been shown that <50% of ICU patients can be classified as responders to intravenous fluids. Unjustified prescription of intravenous fluids may be unfavorable, since fluid overload causes endothelial damage with direct involvement of the glycocalyx, increased vascular permeability to the extracellular space, increased pressure in the encapsulated organs and multisystem edema.

The adverse events most frequently related to volume overload are acute kidney injury (AKI), prolonged hospital stay, pulmonary edema, stroke, increased days of invasive mechanical ventilation (IMV), and increased mortality.

It is common for AKI patients in the ICU to be treated aggressively with intravenous fluids. However, congestive renal failure related to irrational fluid therapy is associated with worse outcomes, as shown in multicenter studies such as REVERSE-AKI 2021 and FINNAKITRIAL, in which restrictive fluid therapy strategies were associated with fewer adverse effects, including balance overall fluid accumulation and mortality.

In septic shock , the Surviving Sepsis Campaign recommendations published in 2021 recommend aggressive intravenous fluid therapy with crystalloids at a dose of 30 ml/kg. However, the evidence supporting this recommendation is weak and increasingly questioned, as multiple cohort studies have shown that only 3% of patients with septic shock will respond to fluids within eight hours of admission and already will not benefit from fluid therapy (Pittard 2017; Cordemans 2012; Flori 2011). Furthermore, a positive fluid balance of more than 2 L is associated with increased mortality.

The role of hidden fluids must also be taken into account, as it represents approximately one-third of the cumulative fluid balance involving fluids from medication vials, intravenous lines, enteral nutrition, and blood products, making the intention for a benefit a cause. Of damage. (Branan 2020).

Intravenous fluid therapy in critically ill patients must be justified milliliter by milliliter and overload must be avoided at all costs.

Sedatives are commonly used in the ICU. Sedation is indicated in patients with moderate to severe acute respiratory distress syndrome (ARDS), patients with intracranial hypertension (ICH), and other settings. The drugs of choice are propofol and dexmedetomidine. However, a large proportion of patients do not require sedation and could be treated only with adequate analgesia and, in case of agitation, anxiolytics or antipsychotics (Park 2019).

Unnecessary sedation is harmful to critically ill patients. A recently published new analysis of the NON-SEDA study showed that patients who remained sedated for agitation or respiratory failure had worse outcomes, including more days of IMV and ICU, as well as a higher incidence of delirium, despite having no impact on mortality (Nedergaard 2022). Prolonged sedation limits early rehabilitation with active mobilization. Benzodiazepines as sedative agents are associated with worse outcomes and are not recommended as first options (Park 2019). In patients with ARDS, daily discontinuation of sedation has been shown to be associated with a decrease in IMV days, hospital stay and mortality (Kress 2000). Combining this strategy with a daily spontaneous ventilation trial may lead to better outcomes (Girard 2008).

Sepsis is one of the most frequent diagnoses in the ICU . Early antibiotic treatment (<1 h) has been associated with better outcomes (Kollef 2021). However, there are patients without confirmed or suspected infections who do not require antibiotics . Unjustified antibiotic prescribing contributes to antimicrobial resistance , which is already a problem in most hospitals with a high incidence of infections due to multidrug-resistant pathogens. Adverse effects that may occur when unnecessary antibiotics are used include mild to severe gastrointestinal disorders (i.e. Clostridioides difficile infection), arrhythmias (azithromycin), seizures (carbapenems), etc. When infection is suspected, cultures should always be requested and therapy adjusted, since antimicrobial administration is safe and is associated with fewer complications (Ilges 2021) and lower mortality.

During the COVID-19 pandemic, inadequate antibiotic treatment has been at its peak. Azithromycin and other macrolides, nitazoxanide, ivermectin, cephalosporins and other drugs have been indicated without evidence of benefit (RECOVERY trial 2020-2021). The overall impact of this therapeutic misconduct remains to be characterized.

Proton pump inhibitors (PPIs) and histamine 2 (H2A) receptor antagonists are commonly used in critically ill patients to prevent gastrointestinal ulcers by decreasing acid production. However, this acid is a barrier to external pathogens , so suppressing its secretion could promote intestinal and lung infections. PPIs can also cause alterations in phagocytosis of leukocyte function and acidification of the lytic phagolysosome (Buendgens 2014; McDonald 2015).

There are many questions regarding whether or not its routine use is beneficial, especially in the absence of a clear indication, such as upper gastrointestinal bleeding . Studies differ in testing benefit in groups using these interventions. On the other hand, adverse events may increase. For example, ventilator-associated pneumonia (VAP), Clostridioides difficile infection (Trifan 2017), longer hospital stay, and no reductions in mortality (Alhazzani 2017; Marker 2018). Enteral nutrition itself may be associated with a decreased risk of gastrointestinal ulcers (Huang 2018).

The transfusion of blood products in critically ill patients has precise indications, such as hemorrhagic shock, severe anemia or coagulopathy. Unnecessary administration of blood products is associated with complications including increased length of hospital stay, transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), increased costs, and increased mortality (Fung 2019).

Lack of knowledge of standardized blood product transfusion protocols results in irrational use in the ICU (Spahn 2019). Currently, restrictive transfusion therapy is associated with better outcomes, and it may be better not to transfuse when hemoglobin levels are between 7 and 8 g/dL without active or massive bleeding (Alexander 2021). Guiding the number and type of transfusions using viscoelastic tests has also not been shown to be better compared to conventional coagulation tests (ITACTIC 2020 trial).

Blood tests for critically ill patients in the ICU have become routine rather than based on diagnostic studies. Blood sampling should only be justified according to the principle of objective intervention (Angus 2014). The usual indication of requesting daily blood samples from patients involves the unnecessary and unjustifiable withdrawal of 40-70 ml of blood every 24 hours (Ñamendys 2019). Consequently, a decrease in hemoglobin of around 1 to 1.2 g per day has been shown (Fung 2019), leading to iatrogenic anemia that may even require transfusion of blood products (Smoller 1989). Prospective trials should aim to reduce the volume of sample collected (pediatric phlebotomy tubes, reduced syringe volumes, etc.).

Pulmonary artery catheterization ( Swan-Ganz catheterization) was popularized in the 1970s for invasive monitoring in the ICU by providing estimated cardiac output through thermodilution and measurement of cavity pressures. right heart, as well as pulmonary circulation. At the end of the last century, a high rate of serious complications associated with this procedure was reported . Several clinical trials failed to demonstrate the benefit of this technique for critically ill patients, so it began to be discontinued (Marik 2013). Being a risky procedure that requires trained medical and nursing personnel to perform measurements correctly, with greater demands on time and resources, this technique has been abandoned in most ICUs.

Transpulmonary thermodilution ( TPT) is an invasive tool that requires the placement of a central venous line (jugular or subclavian) and an arterial line (usually femoral, brachial or radial), which provides information on macrohemodynamics (cardiac output, systemic vascular resistances). , volume statues, etc.) and the patient’s respiratory status (extravascular lung water and pulmonary vascular permeability index). It is used in some ICUs or operating rooms to manage complex patients (Monnet 2017). However, its use to guide hemodynamic management has not been shown to reduce mortality and only improves perfusion in hypotensive patients (Li 2021). Thrombosis and other vascular complications have been reported due to the placement of arterial lines, in addition to the complications of central venous catheterization.

Patients with circulatory shock may benefit from short periods of fasting to avoid intestinal ischemia while improving their macro- and micro-hemodynamic status. Despite this, prolonged fasting and in-hospital malnutrition have been shown to be associated with worse outcomes and higher mortality (Galindo-Martín 2018).

Currently, it is recommended to start with a tolerance test for enteral nutrition (EN) at a trophic dose within 48 hours of admission, with the objective of covering 100% of the caloric requirement (20-30 kcal/kg/day) within 3-7 days from the onset of critical illness (ESPEN 2021). Starting EN with full-dose caloric intake has not been shown to reduce mortality, but may reduce the incidence of adverse events including gastrointestinal intolerance, episodes of hyperglycemia, and increased insulin requirement (EDEN 2012 randomized trial; EAT-ICU trial 2017). Low protein intake is associated with higher infection and mortality rates in critically ill patients. Therefore, it should be included in the nutritional intake (0.8-1.2 g Prot/kg/day). Intakes >1.2 g Prot/kg/day have not been shown to improve outcomes (Lee 2021; Hartl 2022). The cost of nutritional therapy, which may include calorie, protein, fat, or trace element supplements, must also be taken into account.

Overtreatment includes performing interventions that are not desired by the patient and/or do not generate any benefit for the patient. Critically ill patients with terminal chronic illnesses or severe acute pathologies complicated by irreversible organ failure are usually subjected to supportive therapies such as sedation, neuromuscular blockade, fluid therapy, vasopressors, inotropes, blood products, nutrition, antibiotics and other drugs, which will not increase their chances of survival and will only increase the days of hospital stay and the inappropriate use of resources (laboratory and imaging studies, drugs, surgeries, etc.), including admission to the ICU itself (Druml 2019).

The following measures have been proposed for the prevention and recognition of overtreatment in the ICU:

1) Frequent evaluation of therapeutic goals within the medical team in charge, always taking into account the wishes of the patient and their family.

2) High quality multidisciplinary management.

3) Minimize treatment costs and expenses.

4) Strengthen multidisciplinary cooperation through education and training.

5) Promote social discourse about overtreatment (Michalsen 2021).

Humanization and palliative care programs must be implemented with the aim of alleviating or reducing the patient’s pain and suffering, without resorting to useless therapies.

Most critically ill patients remain immobilized, mainly when they are on IMV, in shock, or with severe neurological conditions. Prolonged immobilization has serious consequences, such as weakness (polyneuropathy or myopathy), risk of venous embolism, pressure ulcers, etc. There is a widespread fear of frequent mobilization, as it is commonly believed that a patient who requires vasopressor, mechanical ventilation, ongoing renal failure should not be mobilized on replacement therapy or even ECMO.

Rehabilitation must begin in the ICU. The benefits of early mobilization include improving muscle strength, increasing the patient’s independence, minimizing the complications and risks described above, and promoting home adaptation (Zhang 2019). It should be performed by trained physiotherapy specialists and started when the patient has a minimal or non-significant risk of complications, always following safety parameters, for which it is necessary to monitor vital signs, cardiovascular, neurological and respiratory status (Martinez-Camacho 2021).