Critical Care

Five Tests and Treatments to Question

by
Canadian Critical Care Society
Canadian Association of Critical Care Nurses
Canadian Society of Respiratory Therapists
Last updated: July 2022

Don’t start or continue life supporting interventions unless they are consistent with the patient’s values and realistic goals of care.
1

Patients and their families often value the avoidance of invasive or overly aggressive life-sustaining measures when they are at the end of life. However, many dying patients receive aggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ preferences and to provide recommendations.

Sources:

Canadian Critical Care Society Ethics Committee, Bandrauk N, Downar J, Paunovic B. Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society position paper. Can J Anaesth. 2018 Jan;65(1):105-122. PMID: 29150778

Downar J, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med. 2015 Feb;43(2):270-81. PMID: 25377017.

Myburgh J, et al. End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care. 2016 Aug;34:125-30. PMID: 27288625.

Simons J, Suverein M, van Mook W, Caliskan K, Soliman O, van de Poll M, Delnoij T, Maessen J, Mees B, Lorusso R. Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support? J Clin Med. 2021 Jan 20;10(3):383. doi: 10.3390/jcm10030383. PMID: 33498412.
Don’t prolong invasive mechanical ventilation by over-use of sedatives and/or analgesics and bed rest.
2

Maintaining critically ill patients in an immobile or minimally mobile state during care may potentiate muscle loss and deconditioning. Excessive and/or prolonged use of sedatives is associated with worse outcomes, including increased delirium, excessive use of diagnostic imaging for coma, increased number of tracheostomies, greater duration of mechanical ventilation and ICU length-of-stay.

Sources:

Blackwood B, Tume LN, Morris KP, Clarke M, McDowell C, Hemming K, Peters MJ, McIlmurray L, Jordan J, Agus A, Murray M, Parslow R, Walsh TS, Macrae D, Easter C, Feltbower RG, McAuley DF; SANDWICH Collaborators. Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial. JAMA. 2021 Aug 3;326(5):401-410. doi: 10.1001/jama.2021.10296. PMID: 34342620.

Burry L, et al. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev. 2014 Jul 9;(7):CD009176. PMID: 25005604.

Devlin JW, et al. Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018 Sep;46(9):1532-1548. PMID: 30113371

Schweickert WD, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009 May 30;373(9678):1874-82. PMID: 19446324.

Vagionas D, Vasileiadis I, Rovina N, Alevrakis E, Koutsoukou A, Koulouris N. Daily sedation interruption and mechanical ventilation weaning: a literature review. Anaesthesiol Intensive Ther. 2019;51(5):380-389. PMID: 31893604.
Don’t continue invasive mechanical ventilation without a daily assessment for the patient’s ability to breathe spontaneously using coordinated spontaneous breathing and awakening trials.
3

Screening for readiness for liberation from mechanical ventilation with spontaneous breathing trials allows clinicians earlier recognition of patients that may be liberated from mechanical ventilation.

Sources:

Girard TD, et al. 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 Jan 12;371(9607):126-34. PMID: 18191684.

Girard TD et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med. 2017 Jan 1;195(1):120-133. PMID: 27762595
Don't order routine investigations including chest radiographs or blood tests in critically ill patients, except to answer a specific clinical question.
4

Chest radiographs (“X-rays”, CXRs) are not indicated for routine assessment of critically-ill patients except following specific procedures (e.g., endotracheal tube, naso- or orogastric tube, central vein catheter, or other procedure requiring verification after insertion), or to provide information for a specific question related to a change in patient’s clinical condition. This includes during cases of suspected or confirmed COVID-19. Blood tests should be ordered to monitor a specific clinical condition, or to answer a specific clinical question. At a minimum, the need for recurring or repetitive blood tests should be reassessed daily.

Sources:

Amorosa JK, Bramwit MP, Mohammed TL, Reddy GP, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Jeudy J, Kirsch J, MacMahon H, Ravenel JG, Saleh AG, Shah RD. ACR appropriateness criteria routine chest radiographs in intensive care unit patients. J Am Coll Radiol. 2013 Mar;10(3):170-4. PMID: 23571057.

Ganapathy A, et al. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012 Dec 12;16(2):R68. PMID: 22541022.

Eaton KP et al. Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Intern Med. 2017;177(12):1833-9. PMID: 29049500.

Kotecha N et al. Reducing Unnecessary Laboratory Testing in the Medical ICU. Am J Med. 2017 Jun;130(6):648-651. PMID: 28285068

Routine Blood Tests for Patients in the Intensive Care Unit: Clinical Effectiveness, Cost-Effectiveness, and Guidelines. CADTH. August 16, 2013
Don't routinely transfuse red blood cells in hemodynamically stable ICU patients with a hemoglobin concentration greater than 70 g/l (a threshold of 75 g/L may be considered for patients undergoing cardiac surgery; a threshold of 80 g/L may be considered for patients undergoing orthopedic surgery, those receiving extracorporeal membrane oxygenation and those with active cardiovascular disease).
5

Unnecessary transfusion of red blood cells (RBCs) is more harmful than helpful, and wastes a limited resource, which should be reserved for patients with proven indications. Transfusing RBCs at a threshold higher than 70 g/L does not improve survival in ICU patients, and is associated with more complications and higher costs. This has been extensively studied and a restrictive transfusion strategy results in similar or lower mortality compared with higher thresholds, and other complications, including stroke and infections, may also be reduced.

Sources:

Abbasciano RG, Yusuff H, Vlaar APJ, Lai F, Murphy GJ. Blood Transfusion Threshold in Patients Receiving Extracorporeal Membrane Oxygenation Support for Cardiac and Respiratory Failure-A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth. 2021;35(4):1192-1202. PMID: 33046363.

Carson JL, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016 Nov 15;316(19):2025-2035. PMID: 27732721.

Consensus recommendations for red blood cell transfusion practice in critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19(9): 884-898. PMID: 30180125.

Mistry N, Shehata N, Carmona P, Bolliger D, Hu R, Carrier FM, Alphonsus CS, Tseng EE, Royse AG, Royse C, Filipescu D, Mehta C, Saha T, Villar JC, Gregory AJ, Wijeysundera DN, Thorpe KE, Jüni P, Hare GMT, Ko DT, Verma S, Mazer CD; TRICS Investigators. Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label, randomized, blinded outcome evaluation trial. Diabetes Obes Metab. 2022 Mar;24(3):421-431. doi: 10.1111/dom.14591. Epub 2021 Nov 17. PMID: 34747087.
How the list was created

The Choosing Wisely Canada list of recommendations relevant to critical care was assembled by a collaborative task force from Canadian Critical Care Society (CCCS), Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists and representatives from pharmacy, dietician and physiotherapy. The initial list of items were generated by task force, with support from CCCS Google groups. A modified Delphi method was used to retain 10 items from the initial list. A modified Delphi method was then used to generate domains of interest for ranking items and to select the final list of 5 items. Members of all collaborating societies were surveyed during the 2016 Canadian Critical Care Conference, and for 2 weeks afterwards. Items were modified after review of the survey and feedback from the Choosing Wisely Canada campaign leadership.

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Using Blood Wisely

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Critical Care

Five Tests and Treatments to Question

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