- Overall, ICU mortality continues to improve
REASONS WHY MORTALITY IMPROVEMENT IS NOT FASTER
ARDS as an example:
- Major gains were made with the change to protective lung ventilation, gains since then have been slow
- A number of factors need to be considered, in particular the large amount of background noise making accurate assessment of improvements near impossible.
- Indeed, the studies that have actually shown benefit may not be extrapolatable to the majority of the ARDS population seen in Intensive Care.
- The mortality of ARDS is not usually due to respiratory disease per se, but instead to multiple organ dysfunction, which is due to a multiplicity of factors (including the underlying disease process that resulted in ARDS [eg. pancreatitis, sepsis, burns], inflammatory response due to ARDS, nosocomial infections. No single specific therapy is likely to prevent the cascade of events that result in inflammation. Insufficient studies have been performed to consistently demonstrate one technique has benefits, let alone which combinations of therapies may be useful.
- ARDS is also the end result of a large number of predisposing insults. The outcomes vary dramatically between subgroups (eg. trauma versus pneumonia). More specific classification or stratification may allow more accurate comparisons.
- As a result of better general supportive care, patients that would not previously been considered salvageable could now be going on to develop ARDS, and are more likely to have an adverse outcome
- Potential risk factors as they are discovered are continually being treated/corrected, decreasing the likelihood of less severe/complex cases developing ARDS
- It is probably impossible to accurately compare outcomes now with decades ago, given the inability to control for the many factors that influence outcome
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.