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‘May you live in interesting times’

blessing or curse for an intensivist?

Brzezinski, Marek

Current Opinion in Anesthesiology: April 2019 - Volume 32 - Issue 2 - p 121–122
doi: 10.1097/ACO.0000000000000709

Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA

Correspondence to Marek Brzezinski, MD, PhD, VA Medical Center, Anesthesiology Service (129), 4150 Clement Street, San Francisco, CA 94121, USA. Tel: +1 415 750 2069; e-mail:

Living in interesting times may not always be a blessing, particularly when working in demanding, fast-changing, and complex environment. This applies increasingly to the critical care environment where the intensivist is expected to continually increase clinical productivity while remaining academically active. At the same time, the complexity of teaching, in addition to the learner's expectations, has increased. Furthermore, the push for 24/7 ICU coverage means an extended night call burden for many intensivists. Not surprisingly, there has been an increased concern regarding burnout and reduced satisfaction of critical care providers.

Although opinions on how to address all these complex and challenging issues vary, the first step is to provide the intensivist with current data on the value of different ICU attending coverage models, as well as offer simple yet effective and time-efficient tools to optimize ICU teaching. This special issue on intensive care medicine attempts to address these issues while introducing new ICU trends and providing an update on essential ICU topics:

  1. ICU staffing
    1. One of the more recent hotly debated topics in the ICU has been the 24-h in-house intensive care attending physician coverage. Nizamuddin and Tung (pp. 123–128) critically review the most recent evidence with particular focus on patient care, provider satisfaction, communication with patients, and cost-effectiveness. The authors, coming from one of the leading ICU in the United States, provide conclusions that some may consider somewhat surprising, as they argue that the current evidence does not support a 24/7 in-house intensivist model. They highlight the lack of impact on mortality or other benefit, while pointing out the adverse effects of the 24/7 model. In addition, the authors discuss the unforeseen negative consequences of 24/7 staffing on provider burnout and the growing shortage of intensivists.
    2. One of the commonly mentioned solutions to address ICU staffing has been the rapidly expanding telemedicine in ICU (Tele-ICU or eICU). Becker et al. (pp. 129–135) examine the questions of when, where, and how Tele-ICU adds value. The authors argue that there is growing evidence that the Tele-ICU model improves clinical outcomes, optimizes ICU bed utilization, increases financial performance, and enhances educational opportunities. The authors highlight the importance of administrative buy-in and leadership for Tele-ICU success. This review provides an excellent introduction to Tele-ICU and its potential impact on critical care medicine.
  2. Teaching in the ICU
    1. One challenge faced by the intensivist is providing effective and time-efficient teaching in the ICU, especially given the ubiquitously implemented strategies to increase clinical volume that inevitably reduce teaching time. The wide-spread lack of structured faculty development resources on how to teach effectively in the demanding environment of the ICU further compounds the issue. Brzezinski et al. (pp. 136–143), try to address this issue by providing a review of pertinent educational theories, followed by a selection of simple interventions on how to increase the ‘productivity of teaching per time unit spent,’ concluding with a review on feedback. This is a simple and pragmatic introduction to goal-directed and evidence-based teaching in the fast-paced and high-pressure environment of the ICU.
  3. New topics in the ICU
    1. There is growing evidence that noise, a common insidious pollutant in the ICU, has harmful physiological and psychological effects on both patients and critical care providers. Delaney et al. (pp. 144–149) present a comprehensive synthesis of the epidemiology of noise in the ICU, its impact, and corresponding interventions to reduce noise. The authors argue that noise in the ICU reaches levels likely to have adverse health consequences for both patients and staff. Excessive noise is a substantial contributor to poor sleep and reduced patient satisfaction. The authors discuss noise abatement, environmental masking, and pharmacological interventions that may reduce the impact of noise on patients. This is an important topic, given the pervasive presence of noise and its relevance for patients and providers.
  4. ICU essentials
    1. Not a single day in the ICU goes by without a discussion on what type of noninvasive oxygenation strategy should be used in a patient with acute respiratory failure. To help us parse through this topic, Frat et al. (pp. 150–155) review the recent evidence on noninvasive positive pressure ventilation vs. high-flow nasal cannula oxygen therapy. The authors argue that although noninvasive positive pressure ventilation is the preferred therapy in postoperative patients in addition to those with acute hypercapnic respiratory failure when pH is equal to or below 7.35, high-flow nasal cannula oxygen therapy should be used in patients with de novo acute respiratory failure. This is a well-written article on a topic that has high relevance for both the ICU and operating room.
    2. One of the most controversial topics in critical care has been glucose control in the ICU. To help us better understand why studies looking at the same outcome arrived at opposite conclusions, Gunst et al. (pp. 156–162), reviewed the original as well as the more recent evidence. The authors attend to the methodological differences between the trials and their impact on outcomes to explain the discrepancies in study results.
    3. The definition, diagnosis, and treatment of sepsis continue to evolve and advance. In their very concise and comprehensive review, Nunnally and Patel (pp. 163–168), discuss the implications of the new Sepsis 3 criteria, offer current data regarding intravenous fluid administration, the use of steroids, new drug therapies including vitamin C, thiamine, and angiotensin II; as well as discuss the emerging role of procalcitonin in managing antibiotics. This review is an essential tool for every intensivist.

We live in interesting, changing, but also surprising times, where even the most well meant change can have unpredictable outcomes, such as the lack of clear benefit of 24/7 attending coverage. We clearly have to question more and avoid taking some things for granted just because ‘it makes sense.’ The focus should be on ‘better’ and not solely on ‘more’ – particularly when it comes to ICU delivery of care, coverage and teaching. Current and objective data are key prerequisites in this process, allowing the intensivists to lead such a discussion and remain leaders of change.

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Financial support and sponsorship

M.B. received research support from Grifols Inc. and Trevena Inc.

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Conflicts of interest

There are no conflicts of interest.

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