Much of what we now do in Critical Care carries an air of urgency, a pressing need to discover and act, with priorities biased toward a reactive response. However, efficacy often depends not simply upon what we do, but rather on whether, when, and how persistently we intervene. The practice of medicine is based upon diagnosis, integration of multiple sources of information, keen judgment, and appropriate intervention. Timing may not be everything, as the well-known adage suggests, but in the intensive care unit (ICU) timing issues clearly deserve more attention than they are currently given. Successfully or not, the patient is continually attempting to adapt and re-adjust to acute illness, and this adaptive process takes time. Knowing that much of what we do carries potential for unintended harm as well as benefit, the trick is to decide whether the patient is winning or losing the adaptive struggle and whether we can help. Costs of modern ICU care is enormous and the trend line shows no encouraging sign of moderation. To sharpen our effectiveness, reduce hazard, and pare cost we must learn to time our interventions, help the patient adapt, and at times withhold treatment rather than jump in on the impulse to rescue and/or to alter the natural course of disease. Indeed, much of the progress made in our discipline has resulted both from timely intervention when called for and avoidance or moderation of hazardous treatments when not. Time-sensitive ICU therapeutics requires awareness of trends in key parameters, respect for adaptive chronobiology, level-headed evaluation of the need to intervene, and awareness of the costs of disrupting a potentially constructive natural response to illness.
Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM. Canadian Critical Care Trials Group. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364(14):1293–304. CrossRefPubMed
Cannon WB. The wisdom of the body. New York: W.W. Norton & Co; 1932.
Hart WH, Jauch KW. Metabolic self-destruction in critically ill patients: origins, mechanisms and therapeutic principles. Nutrition. 2014;30(3):261–7. CrossRef
Maccagnan BA, Besen P, Gobatto AL, Melro LM, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: an overview. World J Crit Care Med. 2015;4(2):116–29. CrossRef
Suzumura EA, Figueiró M, Normilio-Silva K, Laranjeira L, Oliveira C, Buehler AM, Bugano D, Amato MB, Carvalho CR, Berwanger O, Cavalcanti AB. Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med. 2014;40:1227–40. CrossRefPubMed
Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guérin C, Prat G, Morange S, Roch A. ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–16. CrossRefPubMed
Sessler CN, Gay PC. Are corticosteroids useful in late-stage acute respiratory distress syndrome? Respir Care. 2010;55(1):43–55. PubMed
Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, Griffiths RD, Heyland DK, Hiesmayr M, Iapichino G, Laviano A, Pichard C, Singer P, Van den Berghe G, Wernerman J, Wischmeyer P, Vincent JL. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19:35. CrossRefPubMedPubMedCentral
Blum CA, Nigro N, Briel M, Schuetz P, Ullmer E, Suter-Widmer I, Winzeler B, Bingisser R, Elsaesser H, Drozdov D, Arici B, Urwyler SA, Refardt J, Tarr P, Wirz S, Thomann R, Baumgartner C, Duplain H, Burki D, Zimmerli W, Rodondi N, Mueller B, Christ-Crain M. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385:1511–8. CrossRefPubMed
Torres A, Sibila O, Ferrer M, Polverino E, Menendez R, Mensa J, Gabarrús A, Sellarés J, Restrepo MI, Anzueto A, Niederman MS, Agustí C. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. JAMA. 2015;313(7):677–86. CrossRefPubMed
Steinberg KP, Hudson LD, Goodman RB, Hough CL, Lanken PN, Hyzy R, Thompson BT, Ancukiewicz M, National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med. 2006;354(16):1671–84. CrossRefPubMed
Mehta S, Cook D, Devlin JW, Skrobik Y, Meade M, Fergusson D, Herridge M, Steinberg M, Granton J, Ferguson N, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Mallick R, Reynolds S, Keenan S, Burry L. SLEAP Investigators; Canadian Critical Care Trials Group. Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults. Crit Care Med. 2015;43(3):557–66.
Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW, BRAIN-ICU Study Investigators. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306–16. CrossRefPubMedPubMedCentral
Gorney C. On the Road again and again, Runners World. 2006. p. 68–74.
Blanch L, Villagra A, Sales B, Montanya J, Lucangelo U, Luján M, García-Esquirol O, Chacón E, Estruga A, Oliva JC, Hernández-Abadia A, Albaiceta GM, Fernández-Mondejar E, Fernández R, Lopez-Aguilar J, Villar J, Murias G, Kacmarek RM. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 2015;41(4):633–41. CrossRefPubMed
Husse J, Eichele G, Oster H. Synchronization of the mammalian circadian timing system: light can control peripheral clocks independently of the SCN clock: alternate routes of entrainment optimize the alignment of the body's circadian clock network with external time. Bioessays. 2015;37(10):1119–28. CrossRefPubMedPubMedCentral
McClintick J, Costlow C, Fortner M, White J, Gillin JC. Partial night sleep deprivation reduces natural killer and cellular immune responses in humans. FASEB J. 1996;10(5):643–53. PubMed
Simons KS, Laheij RJ, van den Boogaard M, Moviat MA, Paling AJ, Polderman FN, Rozendaal FW, Salet GA, van der Hoeven JG, Pickkers P, de Jager CP. Dynamic light application therapy to reduce the incidence and duration of delirium in intensive-care patients: a randomised controlled trial. Lancet Respir Med. 2016;4(3):194–202. CrossRefPubMed
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126–34. CrossRefPubMed
Mekontso-Dessap A, Roche-Campo F, Kouatchet A, Tomicic V, Beduneau G, Sonneville R, Cabello B, Jaber S, Azoulay E, Castanares-Zapatero D, Devaquet J, Lellouche F, Katsahian S, Brochard L. Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial. Am J Respir Crit Care Med. 2012;186(12):1256–63. CrossRefPubMed
- Time-sensitive therapeutics
John J. Marini
- BioMed Central
Neu im Fachgebiet AINS
Meistgelesene Bücher aus dem Fachgebiet AINS
Mail Icon II