Every time you subject the patient to an invasive procedure you take the risk of causing complication. I have done hundreds if not thousands of procedures which makes me even more aware of the risk I take every time I stick a needle or cut into the patient. We can do everything possible to enhance the safety, yet we cannot completely eradicate the risk of adverse events.

With the recent progress in the imaging technology more and more patients opt for a virtual procedure or study with no needles involved. Nowadays, you can undergo virtual colonoscopy (see image above) without the discomfort of the bowel prep and the procedure itself. The risk of complications is also greatly reduced. The sensitivity of the virtual test, of course, is not as good as that of a real colonoscopy. The technology keeps getting better and it is only a matter of time until it becomes the standard of care.

Some medical centers currently offer virtual coronary angiography to diagnose coronary artery disease. No doubt, that it has its limitations and disadvantages but it is also safer than conventional coronary angiography. Once again, the technology has a long way to go, but it’s a start.

In surgery, performing procedures with a minimally invasive approach is nothing new. If you can take a gallbladder out with a laparoscopic approach and avoid making a big incision in the abdomen, this will facilitate healing and minimize complications. Even cardiac surgery could be done minimally invasive if appropriate.

The minimally invasive concept could be applied not only to surgeries and procedures but to the overall patient management approach. A study published in the June of 2008 issue of the Annals of Internal Medicine indicated that ICU patients managed primarily by critical care physicians might, actually, do worse than the patients treated without am intensivist’s involvement.

This article delivered quite a shock to the Critical Care Medicine community. Multiple editorials followed to dismiss the results of this study. One of the possible explanations offered by the authors of this publication was the possible harmful effects of the increased intensity of care.

Invasive procedures like central lines, arterial lines and intubations are considered to be fundamental to the practice of critical care. The authors suggested that critical care physicians simply “overdo” it. Performing more invasive procedures on the patients will, invariably, increase the risk of adverse events.

I will not try to refute the conclusions of that study, but try to learn from it. In many cases you can effectively treat and resuscitate the patient without performing risky procedures. Patients with gastrointestinal bleeding, for example, could often be supported by using a peripheral IVs rather than central line.

In conclusion, many future patients will opt for needle-free, risk-free procedures and treatments. As far as physicians go, taking the “don’t just do anything, stand there” approach might be the right thing to do for the patient in some circumstances.

Resurrection from the dead is more of a subject for science fiction and horror movies. There is a great interest for anything related to resurrection from the general public. According to the Google keyword tool, there were more than 2.7 mil searches on just the word “resurrection” in the past month.

In the Critical Care Medicine we do not practice science fiction or, hopefully, not horror. The process of being dead and able to come to life without any outside intervention is called autoresuscitation. A more scientific definition of autoresuscitation is a resumption of spontaneous circulation without CPR in the patient who previously met criteria for cardiac death. The criteria for cardiac death in these cases, primarily, based on circulatory death – lack of pulse.

The term “autoresuscitation” is much less sexier and less known to the general public. According to the same Google tool, the term has been searched for just 58 times in the last month. Compare that to 2.7 million plus for “resurrection”.

So, what is the significance of autoresuscitation in daily clinical practice?

If you practice Critical Care long enough and have run enough cardiac arrest codes, you will have a couple of “Oops moments” when the patient comes after you have pronounced him dead. I know a case of the patient coming back after the family had been notified.

For the most part, though, autoresuscitation is a rare occurrence in clinical practice. It is, however, a very important consideration for organ donation purposes.

If the patient is brain dead, the organs could be taken at any point as long as the patient remains hemodynamically stable. Donation after cardiac death or DCD has been gaining popularity due to a huge shortage of donors. In the nutshell, for DCD purposes, the patient is taken off life support in the operating room. As soon as the patient meets criteria for circulatory death (lack of pulse) the organs could be harvested.

The tricky part about DCD is to determine how soon it is “safe” to take the organs once the patient is pronounced dead. In other words, how long do you have to wait to rule out the possibility of autoresuscitation? You don’t want to wait too long since every minute of ischemic time will decrease the viability of the organs. At the same time, if the patient regains pulse during the donation process, it will violate the federal “dead donor” rule. Taking organs from an “alive” or not yet dead person is simply illegal – and for a good reason.

The current wait time is anywhere from two to ten minutes. This recommended time interval is primarily based on some previous observations of autoresuscitation after cardiac death.

A study published in the May 2010 issue of the Critical Care Medicine Journal attempts to systemize the literature available on this topic and come up with reasonable recommendations.

According to this study, there were 32 cases of autoresuscitation reported in the literature. The times of occurrence range from a few seconds to 33 min. When the appropriate monitoring was utilized, the longest time to spontaneous resumption of circulation was 7 minutes.

The interesting part is that all 32 cases were reported after failed CPR. No cases of autoresuscitation were ever reported after a controlled withdrawal of care without CPR. What that means is that autoresuscitation is possible not because of the general tendency of dead patients to “come back”, but because CPR itself could preclude the patient from regaining circulation. And once the CPR is stopped…the patient comes back.

This drives home the point that, when performed unskillfully, CPR and resuscitation in general can cause more harm. CPR and hyperventilation during resuscitation is known to create a positive intrathoracic pressure, diminishing venous return to the heart. The case of autoresuscitation that I previously described was due to air trapping and auto-PEEP in the patient with preexisting COPD.

In conclusion, there are no cases of autoresuscitation ever described after withdrawal of care without CPR. In the cases that were described, CPR was attempted or performed prior to the “miraculous” come back. CPR was likely attributed to the problem.

As far as daily clinical practice goes – sorry, we don’t do resurrection…

I have written a lot about the importance of effective communication between the physician and the family in the ICU setting. Critically ill patients are often unable to make their own decisions regarding end-of-life care and this responsibility falls on the shoulders of their surrogate decision-makers.

The patient’s prognosis or chances for recovery is one of the most important questions being asked by the family. The surrogate has to know the likely prognosis and outcome to be able to make the decisions on behalf of the patient.

I often find communicating the prognosis for recovery to the family challenging. Sometime, it’s plain obvious to the healthcare providers that the patient is dying, yet the family simply “doesn’t get it”. Using techniques like repetition and associations might help to deliver the message. Yet, occasionally, the gap in the perception of prognosis persists.

A very interesting study conducted in California and published in the Critical Care Medicine Journal looks at the factors that, actually, influence the perception of prognosis by the surrogate decision makers.

Astoundingly, only 2% of surrogates base their view of the patient’s prognosis solely on the physician’s estimate. And 47% reported basing only part of their own prognosis on the physician’s opinion. Obviously, we are not doing a very good job.

According to this study multiple factors other than the physician’s opinion about the likely outcome influence the surrogate’s perception of the prognosis.

Twenty seven percent of surrogates considered the patient’s intrinsic qualities and will to live or die as a determinant of the outcome. I often hear: “she is a fighter…she will pull through” after I’ve just explained why the patient is not going to survive. Sometimes, I hear the opposite, people tell me “he’s lost his will to live a long time ago”.

The patient’s physical appearance and status, undoubtedly, affect the perception of prognosis. Many times I have been told by the family of the patient with a massive head injury that “he moved his arm… we think he is getting better”. Some motor reflexes happen on the level of the spinal cord and could still be present with a massive brain damage. On the contrary, when the patient is lying in bed cyanotic and mottled that appearance could help “persuade” the family the patient is dying.

Knowledge of the patient’s previous medical history and recovery might influence the decision as well. “He had pneumonia after he was treated for cancer before and survived. He is going to make it now”- the wife of the patient with metastatic lung cancer once told me.

Some family members and surrogates think that their mere presence at the bedside and encouragement might make a significant difference in the outcome. I never discourage anyone to visit the patient as long as it is not interfering with the medical care.

Personal beliefs and qualities like optimism and intuition have a huge influence on the perception of prognosis. Sometimes, I spend hours talking to the family again and again and at the end I hear something like “the God is looking over him…we believe the miracle will happen”. There is no problem with believing in God or a miracle as long as we not putting the patient through unnecessary procedures, surgeries or tests.

Being aware of and understanding the factors influencing the perception of prognosis by the family and surrogate decision-makers is extremely important for establishing an effective communication channel with the family and, ultimately, making the right decision for the patient.

According to Webster’s Dictionary, death is the permanent cessation of all vital functions. In my book death happens when I am no longer able to keep the patient alive or when we should not be keeping the patient alive. In the later case, keeping the patient alive is unethical, unreasonable and has no future benefit for the person. This is probably a simplified view of what happens in the Intensive Care Unit, but it’s true.

For every patient that dies in the ICU I get a death certificate that has to be filled out. Along with the patient’s name, DOB, SSN I have to document the cause of death.

Coming up with the real or leading cause of death sometimes gets complicated. Most patients die from cardiorespiratory arrest – the heart stops and the patient is no longer breathing. Some patients are declared brain dead when the primary insult causes cessation of brain function. Since all patients die when their heart stops, it’s what led to this arrest that should be considered the cause of death.

In many cases it’s fairly easy. For example the patient might die from an overwhelming lung injury caused by pneumonia. The patient might become brain dead after a severe head injury etc.

In some cases, things happen so quickly that you never have a chance to figure it out. If the patients presents with a low blood pressure and arrests on your door step, there could be multiple conditions leading to this. With the declining rate of autopsies you might not have the benefit of the postmortem exam to “satisfy your curiosity”.

In some cases the sequence of events could be so complex that coming up with ultimate cause of death becomes tricky. For example, the patient with a cancer was given chemotherapy reducing his blood counts. Having no white cells to fight the infection the patient developed overwhelming sepsis and renal failure. Low blood pressure and tachycardia increased metabolic demand on the patient’s heart leading to the heart attack. The patient goes into a cardiac arrest and suffers anoxic brain injury; the family decides to withdraw care based on a poor prognosis.

Even thought the patient died from anoxic brain injury, the ultimate culprit of his death was cancer triggering the cascade of unfortunate events.

Documenting the correct cause of death is important not only for the statistical purposes but important for the family of the patient as well. Knowing what their loved one ultimately died from might provide closure and peace.

Admission to the Intensive Care Unit is a very stressful event for the family of the critically ill patient. It is even more stressful when the patient is doing poorly and is at a higher risk of dying. Physicians rely on the family members to make important decisions when the patient is unable to communicate. If you ever been present at a meeting with the family of the critically ill patient, you would notice that the level of stress and anxiety is extremely high among the family members.

Functioning under significant amount of stress is hard enough. Not to mention that making life and death decisions for their loved ones puts a tremendous amount of pressure on the family members. As physicians we should be aware of the significant psychological symptoms burden in family members. Several techniques, like using associations and repetition, previously described in this blog, might facilitate the family’s understanding of the disease process and treatment options.

A recent study published in the April issue of the Critical Care Medicine Journal attempts to quantify the prevalence of psychological symptoms among family members of the critically ill patients with a high risk of dying. This is only a small study, yet it offers invaluable insights into the psychological state of the family members.

The investigators documented the symptoms of traumatic stress in 56.8%, anxiety in 79.7% and depression in 70.3% of the family members 3 to 5 days after the patient’s admission to the ICU. Many family members reported fear, worry, exhaustion, helplessness, sadness and anger according to this study. Factors associated with higher traumatic stress levels were younger patient’s age, younger family member age and female gender of the family member.

This study primarily focuses on the short term psychological consequences after the admission to the ICU. Previous studies found that 34% of the surrogate decision makers met criteria for complicated grief, major depression and anxiety disorder 3 to 12 months after the ICU experience.

Post traumatic stress disorder was documented in 35% of family members 6 months after the ICU experience. 46% of family members had complicated grief.

It is important to appreciate the psychological state of the family members after their loved one has been admitted to the ICU. As clinicians, we have a chance to intervene and relieve the psychological burden by conducting structured family conferences and acknowledging family’s feelings and emotions. It is also extremely important to be aware of the family’s psychological status when end of life decisions are to be made.

Obesity is a huge healthcare problem in the United States. It has reached the proportions of an epidemic and continues to get worse. Multiple medical problems including heart disease, hypertension, diabetes, sleep apnea and cancer are closely associated with obesity. The patients with extreme obesity can reach a body weight of five, six or seven hundred pounds and even higher. Riddled with chronic medical conditions, these patients often end up in the hospital for medical care. Taking care of the extremely obese patient presents many challenges for the practicing physicians. Below are some practical considerations for how deal with extremely obese patients in the hospital and ICU.

Just moving the patient in bed or even getting the patient out if bed presents a challenge. The ceiling lifts come very handy even to just flip the patient on the side. Even those lifts have a weight limit, so now we are considering getting at least one ceiling lift with a 1000 pounds weight limit for each floor…

Obtaining a radiographical study on an obese patient could be quite difficult. Plain XR of the chest is often unreadable due to its poor quality. Obtaining more involved studies like CT scan or MRI even more challenging. Most radiology equipment has a weight limit and, sometimes, you simply cannot fit the patent into the scan because of the size limits. There were circumstances where we had to perform a diagnostic laparotomy when an acute abdomen was suspected because no useful images could be obtained.

Obese patients often have hypoventilation and sleep apnea, putting them at a higher risk for respiratory failure. Intubating an obese patient could be an absolute nightmare. Using GlideScope or even a bronchoscope might help when dealing with a difficult airway.

Venous access is often problematic as well. The amount of abdominal tissue overlying the groin often precludes the placement of a femoral central venous catheter. Using an ultrasound for the placement of an internal jugular central catheter is helpful if central line is needed. In many cases having a PICC line (percutaneously inserted central catheter) inserted could save you’re a lot of time and effort.

Once the patient is on ventilator, the excessive amount of thoracic adipose (fat) tissue leads to high ventilatory pressures. The shear weight of this tissue compressing the chest precludes the lung from adequate expansion. Thus, higher pressures are required to ventilate the patient, increasing the risk of complications. Tracheostomy often becomes the only option to wean the patient off the ventilator.

DVT (deep venous thrombosis – primarily in lower extremities) prophylaxis is at best uncertain. Many obese patients are bedridden while being in the ICU and are at increased risk for venous blood clots in their legs. The usual method of prophylaxis is the administration of a low dose blood thinner, like Lovenox or Fragmin, under the skin (SQ) of the abdomen. Considering extreme obesity, the absorption of this drug is uncertain.

Wound healing is often impaired in obese patients. This is especially true for abdominal wounds. Many patients end up having a long term VAC dressing (sponge dressing connected to a vacuum device) to keep the wound clean.

Many more practical issues arise when taking care of the extremely obese patients. The problem is not going to go away and will likely to get worse. It’s like the wife of the 700 pound patient had said once I informed her that CT scan was not an option for her husband: “I thought the whole nation is getting fatter. How come you are not prepared for this?”

Every day, while seeing patients in the Intensive Care unit, I have family meetings and conferences to discuss the patient’s condition and outline the treatment plan. In many cases the diagnosis and the treatment are straightforward. If the patient came with pneumonia, intravenous antibiotics will be given and the gradual improvement is expected.

Sometimes, the patient’s condition is far from straightforward. Yet, the family’s understanding and “buying-in” into the treatment plan are important for the patient’s recovery. Using associations and analogies might help to effectively communicate with the family. Another technique that I found useful to “get through” to the family is repetition. Sometimes, you have to repeat the same thing over and over, using different words, of course, for the information to sink in. Let’s look at an example.

An 84 year old previously healthy male presented with urinary tract infection, acute renal failure and sepsis due to an obstructing kidney stone. The patient was started on intravenous antibiotics and the nephrostomy tube was placed to decompress the obstructed kidney. On the second hospital day his condition started to improve. His blood pressure, kidney function and fever have improved. His pain was controlled with oral analgesics.

Despite his overall recovery, on the third hospital day, the patient became restless, agitated and confused. The family requested an urgent meeting with the physician to find out why this highly intelligent retired college professor is jumping out bed naked, hitting nurses and does not even recognize his own wife. The family demands to know “what is going on and what is he being given by the nurses”.

The patient likely has ICU delirium or ICU psychosis. This is a poorly understood condition which is quite common among sick elderly patients admitted to ICU. Multiple factors contribute to this brain disturbance: infection, renal failure, pain medications and overall metabolic derangements including electrolyte misbalance. The list of precipitating factors goes on and on. Preexisting dementia is a big risk factor.

The mood in the conference room is tense. The family is visibly distraught and frustrated. Making a statement like “It is not surprising that your father/husband developed this condition since the brain is often affected when the rest of the body is sick” may ease the tension a bit. Understanding that this is quite common might make the family feel somewhat better.

Acknowledging that “yes, the pain medications that are being appropriately given to the patient might contribute to this condition as well as the kidney failure, infection, electrolyte disbalance…”

It is also important to outline the likely course of the condition by saying “Once overall clinical status has improved and his kidney function returns to normal and the infection is controlled, we will see a gradual return to the baseline”, thus, repeating the clinical concept again to facilitate understanding and retention.

At the end of the conversation the family was quite comfortable with the explanation and the treatment plan. The family expressed their understanding of the patient’s condition and precipitating factors. His wife also admitted that even though he has never been diagnosed with dementia, “his memory is not what it used to be”.

On the fifth hospital day the patient’s condition started to improve. His neurological status later returned to baseline. Hi was discharged home in good condition.