Table 1 Example of the phases-of-illness paradigm phase criteria and supportive care goals
From: Phases-of-illness paradigm: better communication, better outcomes
| Â | Phase 1 - Acute (6 to 24 hours; few patients) | Phase 2 - Stabilization (2 to 4 hours, often days in TBI) | Phase 3 - Stable/weaning (usually lasts 24 to 72 hours) | Phase 4 - Recovery (indefinite; most patients) |
|---|---|---|---|---|
Criteria | • Presence of shock - SBP < 90 after fluid bolus - An elevated lactate (> 2 to 4) - Decreased SvO2 or ScvO2 (< 70% or < 65%) • Active resuscitation: medications, drips, and therapies are rapidly added and/or changed • Rapid fluid/blood product infusions • Respiratory failure and need for advanced mechanical ventilation • Increasing extracorporeal life support for organ failure • Aggressive ICP management - Frequent osmolar therapy, CSF drainage, pending need for craniectomy • Initial 8 to 12 hours of burn resuscitation • The need for organ support | • SvO2 or ScvO2 has normalized • Lactate has normalized or continues to decrease • Stable vasopressor requirement for 2 to 4 hours • No new therapies for 2 to 4 hours • No fluid bolus for 2 to 4 hours • Stable ventilator settings, but unable to wean (not on extracorporeal lung support) • Not on high volume CRRT • • Continued ICP elevations requiring intervention more than every 12 hours • 8 to 36 hours of burn resuscitation • The need for organ support | Stable • Admitted to or in the ICU primarily for monitoring purposes - One-to-one nursing, or invasive monitoring not supported elsewhere in the hospital Weaning • The patient is getting better • Vasoactive drips are being decreased or weaned off • Ventilator settings are being weaned or modes changed to CPAP or pressure support - Possible extubation • Active or passive dieresis • Renal support CRRT • Reducing the need for organ support | • No vasoactive drips • Diuresing or euvolemia • Liberated or attempting to liberate from mechanical ventilation or unable to liberate due to long-term condition • Invasive devices are being removed • The patient is being mobilized (PT/OT) • Transition to intermittent hemodialysis • No need for organ support |
Goals | Â | Â | Â | Â |
General supportive | Global or organ specific (for example, acute lung injury) resuscitation • To assess and maintain vital organ perfusion by: - Volume resuscitating - Maintaining adequate perfusion pressure with continuous vasopressor medications - Achieve a normal ScvO2 or SvO 2 and/or a down trending lactate • To achieve adequate gas exchange to perfuse organs utilizing advanced mechanical ventilation and or extracorporeal support therapies • To prevent uncal herniation and brain death | • To continue resuscitation as needed, likely with less frequent interventions • To maintain stabilization achieved during the resuscitative phase • To ensure nothing is being missed (that is, all diagnoses accounted for, all supportive therapies like feeding, DVT/stress ulcer prophylaxis, and day/night cycling are applied) | Stable • To closely monitor the patient for potential worsening of a specific condition such as: - Neurologic decline, Respiratory distress, Extremity compromise, (vascular/neurologic), Hemodynamic compromise. Weaning • To decrease resuscitative support - Wean-off vasopressor Therapy - Decrease/remove IVF - Wean ventilator support - Reduce organ support Both • Minimize cognitive harm and physical wasting • Interaction | • To remove invasive devices - Cannula(e), ETT, central line, arterial line, Foley, and so on • To ready the patient for transfer or discharge - Discontinue continuous drips - Decrease monitoring - Stopping ICU-related medications (such as stress ulcer prophylaxis, intensive insulin therapy, and so on) • Reestablish patient self-control and function |
Analgesia/ sedation support | Controlled sedation for: safety, rest, and decreased metabolic demand. Avoid sedative-induced hypotension | Assess neurologic function with awakening trial/re-establish awareness. Maintain and prioritize pain control | A pain-free, awake, and interactive patient that can participate in care. Avoid respiratory depressants | Pain-free and participative in care Transition to as needed, preferably oral/enteral medication |
Ventilation | Safety, rest, and control; avoid VILI | Respiratory work to avoid atrophy; avoid VILI | Comfortable spontaneous breathing. Possible extubation | Comfortable spontaneous breathing, preferably without an endotracheal tube (that is, NIPPV or tracheostomy) |
Mobility | Maintain range of motion | Facilitate awareness, change position to minimize atelectasis | Re-establish postural tone. Maintain strength | Rehabilitation, independence |