Abstract
The intensive care unit (ICU) continues to be a large user of resources. There is a continued need for a balance of cost-effective utilization and quality patient care. A data base of information currently exists that defines those groups of patients in whom reasonable success in resource allocation can be anticipated. In other cases, attempts are being made to define variables that adequately predict survival so they can be used to effect care decisions. Although some progress has been made, considerable work is needed to achieve both of these.
For surgeons, the ICU has become an essential “part of the knife.” It is a necessity in modern high-technology care and has become an essential element in surgical training programs. The use of the ICU for currently conceived high-risk patients is now commonplace. A growing database supports this preoperative use of ICU resources. Techniques are now available to make ICU care more cost-effective. Tools such as not having routine orders, daily rewriting of all orders, review of drug orders, and the utilization of the laboratory and radiographic resources have already reduced significantly the real cost of using these life-saving facilities.
Résumé
L'unité de soins intensifs reste un service très onéreux. Il est donc indispensable d'établir un juste équilibre entre les coûts et les services rendus efficacement. Une accumulation de données permet de définir les groupes de malades chez qui il est possible d'escompter le bon emploi des investissements engagés. D'autre part, des essais sont entrepris pour définir les variables qui permettent de prédire de manière adéquate la survie et ainsi d'orienter les décisions thérapeutiques. Bien que des progrès aient été réalisés en ce sens, un travail considérable reste à entreprendre pour atteindre ces deux buts.
Pour le chirurgien, le traitement dispensé à l'unité des soins intensifs est devenue une partie essentielle du traitement chirurgical. Il constitute une part indispensable du traitement par une haute technologie moderne et il est devenu une part essentielle de l'enseignement chirurgical. L'emploi courant des soins intensifs pour les malades considérés comme des patients à haut risque est maintenant un lieu commun. Des données croissantes appuient l'emploi pré-opératoire des ressources des soins intensifs. Des techniques sont dès maintenant disponibles pour rendre les soins moins onéreux. Il en est ainsi de la suppression des soins de routine et de la prescription des soins au jour le jour, de la remise en cause également des prescriptions médicamenteuses et de l'utilisation des données biologiques et radiologiques. Ces mesures ont déjà réduit significativement le coût réel des soins vitaux.
Resumen
La unidad de cuidado intensivo (UCI) sigue siendo un gran consumidor de recursos. Hay una necesidad permanente de lograr un equilibrio entre una utilización costo-efectiva y la calidad de la atención al paciente. Ya existe acúmulo de información para definir aquellos grupos de pacientes en los cuales se pueda anticipar un razonable éxito en cuanto a la asignación de recursos. En otras situaciones se hacen esfuerzos para definir variables capaces de predecir adecuadamente la supervivencia, en tal forma que puedan ser utilizadas para la toma de decisiones relativas a manejo. Aunque considerable progreso ha sido logrado, todavía es necesario realizar trabajo adicional para su plena implementación.
Para los cirujanos, la UCI ha venido a convertirse en parte de la operación; es una parte necesaria de la moderna atención de alta tecnología y es parte esencial de los programas de adiestramiento quirúrgico. El uso de la UCI para pacientes considerados de alto riesgo es común. Un creciente cuerpo de información da apoyo a este uso preoperatorio de los recursos de la UCI. Ya hay técnicas disponibles para hacer la atención de UCI más efectiva. Factores tales como no tener órdenes rutinarias, reescribir diariamente la totalidad de las órdenes, la revisión de las órdenes de drogas, y la utilización de los recursos de laboratorio y radiográficos, ya han reducido significativamente el costo real de estas facilidades salvadoras de vidas.
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References
Thompson, W.L.: Critical care tomorrow: Economics and challenges. Crit. Care Med.10:561, 1982
Madoff, R.D., Sharpe, S.M., Fath, J.J., Simmons, R.L., Cerra, F.B.: Prolonged surgical intensive care. Arch. Surg.120:698, 1985
Feller, I., Tholen, D., Cornell, R.G.: Improvements in burn care, 1965–1979. J.A.M.A.244:2074, 1980
Lown, B., Fakhro, A.M., Hood, W.B., Thorn, G.W.: The coronary care unit. J.A.M.A.199:188, 1967
Williams, R.L., Chen, P.M.: Identifying the sources of the recent decline in perinatal mortality rates in California. N. Engl. J. Med.306:207, 1982
Paneth, N., Kiely, J.L., Wallenstein, S., Marcus, M., Pakter, J., Susser, M.: Newborn intensive care and neonatal mortality in low-birth-weight infants. N. Engl. J. Med.307:149, 1982
Siegel, J.H., Cerra, F.B., Moody, E.A., Shetye, M., Coleman, B., Garr, L., Shubert, M., Keane, J.S.: The effect of survival of critically ill and injured patients of an ICU teaching service organized about a computer-based physiologic CARE system. J. Trauma20:558, 1980
Shoemaker, W.C., Appel, P., Bland, R.: Use of physiologic monitoring to predict outcome and to assist in clinical decisions in critically ill postoperative patients. Am. J. Surg.146:43, 1983
Shoemaker, W.C., Appel, P.L., Waxman, K., Schwartz, S., Potter, C.: Clinical trial of survivors' cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients. Crit. Care Med.10:398, 1982
Rogers, R.M., Weiler, C., Ruppenthal, B.: Impact of the respiratory intensive care unit on survival of patients with acute respiratory failure. Chest62:94, 1972
Del Guercio, L.R.M., Cohn, J.D.: Monitoring operative risk in the elderly. J.A.M.A.243:1350, 1980
Rao, T.L.K., Jacobs, K.H., El-Etr, A.A.: Reinfarction following anesthesia in patients with myocardial infarction. Anesth.59:499, 1983
Hook, E.W., III, Horton, C.A., Schaberg, D.R.: Failure of intensive care unit support to influence mortality from pneumococcal bacteremia. J.A.M.A.249:1055, 1983
Teplick, R., Caldera, D.L., Gilbert, J.P., Cullen, D.J.: Benefit of elective intensive care admission after certain operations. Anesth. Analg. (Cleve.)62:572, 1983
Griner, P.F.: Treatment of acute pulmonary edema: Conventional or intensive care? Ann. Intern. Med.77:501, 1972
Mulley, A.G., Thibault, G.E., Hughes, R.A., Barnett, G.O., Reder, V.A., Sherman, E.L.: The course of patients with suspected myocardial infarction: The identification of low risk patients for early transfer from intensive care. N. Engl. J. Med.302:943, 1980
Shimazu, S., Clayton, H.S.: Outcomes of trauma patients with no vital signs on hospital admission. J. Trauma23:213, 1983
Pallis, C.: ABC of brain stem death: The arguments about the EEG. Br. Med. J. (Clin. Res.)286:209, 1983
Levy, D.E., Caronna, J.J., Singer, B.H., Lapinski, R.H., Frydman, H., Plum, F.: Predicting outcome from hypoxic-ischemic coma. J.A.M.A.253:1420, 1985
Longstreth, W.T., Jr., Inui, T.S., Cobb, L.A., Copass, M.K.: Neurologic recovery after out-of-hospital cardiac arrest. Ann. Intern. Med.98:588, 1983
Bellamy, P.E., Oye, R.K.: Adult respiratory distress syndrome: Hospital charges and outcome according to underlying disease. Crit. Care Med.12:622, 1984
Binnie, C.D., Prior, P.F., Lloyd, D.S.L., Scott, D.F., Margerison, J.H.: Electroencephalographic prediction of fatal anoxic brain damage after resuscitation from cardiac arrest. Br. Med. J.4:265, 1970
Alving, J., Moller, M., Sindrup, E., Nielsen, B.L.: “Alpha pattern coma” following cerebral anoxia. Electroenceph. Clin. Neurophysiol.47:95, 1979
Bull, J.P., Fisher, A.J.: A study of mortality in a burns unit: A revised estimate. Ann. Surg.139:269, 1954
Pruitt, B.A., Jr., Tumbusch, W.T., Mason, A.D., Jr., Pearson, E.: Mortality in 1,100 consecutive burns treated at a burns unit. Ann. Surg.159:396, 1964
Curreri, P.W., Luterman, A., Braun, D.W., Jr., Shires, G.T.: Burn injury: Analysis of survival and hospitalization time for 937 patients. Ann. Surg.192:472, 1980
Pine, R.W., Wertz, M.J., Lennard, E.S., Dellinger, E.P., Carrico, C.J., Minshew, B.H.: Determinants of organ malfunction or death in patients wtih intra-abdominal sepsis. Arch. Surg.118:242, 1983
Knaus, W.A., Draper, E.A., Wagner, D.P., Zimmerman, J.E.: Prognosis in acute organ-system failure. Ann. Surg.202:685, 1985
Wagner, D.P., Knaus, W.A., Draper, E.A., Zimmerman, J.E.: Identification of low-risk monitor patients wtihin a medical-surgical intensive care unit. Med. Care.21:425, 1983
Civetta, J.M., Hudson-Civetta, J.A.: Maintaining quality of care while reducing charges in the ICU. Ann. Surg.202:524, 1985
Pontoppidan, H.: Mechanical aids to lung expansion in nonintubated surgical patients. Am. Rev. Respir. Dis.122:109, 1980
Ayres, S.M.: Magnitude of use and cost of inhospital respiratory therapy. Am. Rev. Respir. Dis.122:11, 1980
Belman, M., Mittman, C.: Incentive spirometry: The answer is blowing in the wind. Chest79:254, 1981
Bartlett, R.H.: Postoperative pulmonary prophylaxis: Breathe deeply and read carefully. Chest81:1, 1982
Graham, W.G.B., Bradley, D.A.: Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia. N. Engl. J. Med.299:624, 1978
May, D.B., Munt, P.W.: Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis. Chest75:29, 1979
Lorin, M.I., Denning, C.R.: Evaluation of postural drainage by measurement of sputum volume and consistency. Am. J. Phys. Med.50:215, 1971
Maloney, F.P., Fernandez, E., Hudgel, D.W.: Postural drainage effect after bronchodilator inhalation in patients with chronic airway obstruction. Arch. Phys. Med. Rehabil.62:452, 1981
Anthonisen, P., Riis, P., Sogaard-Andersen, T.: The value of lung physiotherapy in the treatment of acute exacerbations in chronic bronchitis. Acta Med. Scand.175:715, 1964
Baxter, W.D., Levine, R.S.: An evaluation intermittent positive pressure breathing in the prevention of postoperative pulmonary complications. Arch. Surg.98:795, 1969
Becker, A., Barak, S., Braun, E.: The treatment of postoperative pulmonary atelectasis with intermittent positive pressure breathing. Surg. Gynecol. Obstet.111:517, 1960
Sands, J.H., Cypert, C., Armstrong, R.: A controlled study using routine intermittent positive pressure breathing in the postsurgical patients. Dis. Chest40:128, 1961
Celli, B.R., Rodriguez, K.S., Snider, G.L.: A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am. Rev. Respir. Dis.130:12, 1984
Werner, A.S., Cobbs, C.G., Kaye, D., Hook, E.W.: Studies on the bacteremia of bacterial endocarditis. J.A.M.A.202:199, 1967
Franciosi, R.A., Favara, B.E.: A single blood culture for confirmation of the diagnosis of neonatal septicemia. Am. J. Clin. Pathol.57:215, 1972
Washington, J.A., II: Blood cultures: Principles and techniques. Mayo Clin. Proc.50:91, 1975
Weinstein, M.P., Relier, L.B., Murphy, J.R., Lichtenstein, K.A.: The clinical significance of positive blood cultures: A comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev. Inf. Dis.5:35, 1983
Miranda, D.R., Van Saene, H.K.F., Stoutenbeek, Ch.P., Zandstra, D.F.: Environment and costs in surgical intensive care unit. Acta Anaesth. Belg.3:223, 1983
Cuthbertson, D.P.: Post-shock metabolic response. Lancet1:433, 1942
Clowes, G.H.A., Jr., Del Guercio, L.R., Barwinsky, J.: The cardiac output in response to surgical trauma. Arch. Surg.81:212, 1960
Orlando, R., III, Nelson, L.D., Civetta, J.M.: Invasive preoperative evaluation of high risk patients. Crit. Care Med.13:263, 1985
Cole, W.C.: Editorial. Prediction of operative reserve in the elderly patient. Ann. Surg.168:310, 1968
Goldman, L.: Cardiac risks and complications of noncardiac surgery. Ann. Intern. Med.98:504, 1983
Boysen, P.: Preoperative assessment of operative patients as an indicator of postoperative therapy. Vail Symposium in Intensive Care, 1986, pp. 1–20
Bland, R.D., Shoemaker, W.C., Abraham, E., Cobo, J.C.: Hemodynamic and oxygen transport patterns in surviving and nonsurviving postoperative patients. Crit. Care Med.13:85, 1985
Uggla, L.G.: Indications for and results of thoracic surgery with regard to respiratory and circulatory function tests. Acta Chir. Scand.111:197, 1956
Bush, H.L., Huse, J.B., Johnson, W.C., O'Hara, E.T., Nabseth, D.C.: Prevention of renal insufficiency after abdominal aortic aneurysm resection by optimal volume loading. Arch. Surg.116:1517, 1981
Shoemaker, W.C., Bland, R.D., Appel, P.L.: Therapy of critically ill postoperative patients based on outcome prediction and prospective clinical trials. Surg. Clin. N. Am.65:811, 1985
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Eyer, S.D., Cerra, F.B. Cost-effective use of the surgical intensive care unit. World J. Surg. 11, 241–247 (1987). https://doi.org/10.1007/BF01656408
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DOI: https://doi.org/10.1007/BF01656408