4家重症监护相关学会发布明智选择清单

旧金山——4个重症监护学会在重症监护大会(CCC)上联合发布了最新的“明智选择清单”，列举了重症监护医务人员应当避免的5个最重要事项。其中包括一项可能很困难的事宜：除了舒适护理之外，还为患者家属提供停止生命支持的选择。

联合工作组成员、哥伦比亚大学医疗中心麻醉科的Hannah Wunsch医生介绍，这份清单上的第5项可能是最具争议但同时又是代表们最希望纳入的事宜，不论其是否能节省大量资源。“很多患者接受积极的生命维持治疗，在某种程度上是由于临床医生未能了解患者的价值观和目标，未能提供以患者为中心的建议。”

对于这份清单的讨论，很快转为探讨如何实施这些建议，包括如何使患者家属在发现自己的亲人正在被实施这些措施时能够向临床医生提出异议。

这场会议的主办方危重症医学会(SCCM)协同美国胸科医师协会(ACCP)、美国胸科学会(ATS)和美国重症监护护士协会(ACCN)编写了这份清单。协作组主席、宾夕法尼亚大学的Scott D. Halpern医生介绍，这是第一份协同护理组织制定的明智选择清单，同时也是第二份由多个学会制定的明智选择清单。

重症监护学会协作组首先列出了58项存在异议的临床实践，然后根据证据强度、普遍程度、相关性和成本等因素将归纳出9项。经过讨论筛选，最后留下了最重要的5个事项。

有需要者可从明智选择官网上下载这份2页的清单，主要内容如下：

1.不要定期(例如每天)进行诊断性检查，而是应当针对具体的临床问题进行检查。

每天或常规定期进行X线、动脉血气、血细胞计数、血生化或心电图等检查，会增加费用而不能使患者获益，而且可能使患者受到射线暴露等的伤害，包括可引起贫血、因偶然发现而进行积极随访等。“我认为随着电子病历的普及，这种现象正日益常见，例如点击一下鼠标即可安排接下来5天内的X线检查。”

2.不要对血流动力学稳定、血红蛋白水平＞7 mg/dl的非出血性ICU患者输红细胞。

血液是一种珍贵的资源，而且多项研究显示仅在血红蛋白水平＜7 mg/dl的情况下输注红细胞并不会降低生存率、增加并发症或费用，而且并发症反而会减少。对于急性冠脉综合征患者或许应当采用不同的输血阈值，但是即便如此，多数观察性研究提示积极输血仍是有害的。

3.不要在入住ICU的头7天内对营养充足的危重症患者采取肠外营养。

早期肠外营养是有害的，即使对于无法耐受肠内营养的患者也是如此，只要其在入住ICU之前营养充足。对于医院内感染患者的证据不那么清晰，早期肠外营养可能对入住ICU前夕严重营养不良的患者有益。

一项即将发表的研究显示，美国90%的肠外营养是在入住ICU后7天内启动的，常常在头2天内就开始了。

4.不要对无特定适应证的机械通气患者进行深度镇静，而且应当每天尝试减轻镇静。

对机械通气患者进行深度镇静会延长通气和住院的时间。一些限制镇静的方案已显示出改善患者结局的作用。

5.在未向患者及其家属提供完全针对舒适性的护理这一替代选择的情况下，不要对死亡风险高或功能恢复严重受损的患者继续给予生命支持。

当一名与会者表示对中止生命支持可能增加过早死亡的担忧时，Wunsch医生强调，声明的第二部分是关键所在——向家属提供舒适护理或继续生命支持的选择。

匹兹堡大学的Jeremy M. Kahn医生指出，明智选择清单的简明以及其对过度使用和费用的关注，使得它有可能以特有的方式被广为采纳，例如使患者家属能够对医疗提出质疑。例如，这5项推荐意见远少于2002年脓毒症生存行动提出的85项推荐意见，而且明智选择行动已与消费者报告结成伙伴并与大众媒体协作以促进清单的传播。

Kahn医生描述了不久前的一段不快的经历：他对自己的一位亲人在住院时接受的医疗产生了一些疑问，这有些难以启齿，尽管他自己就是一名医生，那么对于一般患者而言必然更加难以说出口。一名与会的医生在讨论时表示，在每个ICU病房内都张贴一份明智选择清单，或许有助于使患者家属能够提出疑问。

Kahn医生表示，将决策-支持融入电子健康档案也有助于临床医生依从明智选择推荐意见。

Wunsch医生介绍，除了被列入明智选择清单的这5个事项之外，另外4项重要事宜包括：抗生素疗程，对不同意识状态患者进行CT或MRI扫描，血管导管指征，以及不良预后患者的ICU入住标准。

美国胸科医师协会候任主席Curtis Sessler医生介绍，重症监护学会协作组代表着大约15万名治疗危重症患者的医务人员。

明智选择行动是ABIM基金会发起的一个项目，在2012年4月组织9个医学会发布了“医生和患者应当质疑的5件事”，2013年2月新增了17个医学会，目前有多份清单正在制定中。

上述发言人报告称无相关利益冲突。

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SAN FRANCISCO – Four critical care societies released a list of the top five things that intensivists should avoid doing, part of the larger Choosing Wisely campaign to reduce unnecessary and costly medical practices. The list includes a potentially difficult issue: offering patients’ families the option of discontinuation of life support in lieu of comfort care.

Fifth on the list, the life-support item may be the most controversial and is also the one that the representatives felt the most strongly about including, whether or not it saves many resources, according to Dr. Hannah Wunsch, who served on the collaborative task force. "Many ... patients receive aggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ values and goals, and to provide patient-centered recommendations," the task force wrote.

Discussion of the list, which was announced at the Critical Care Congress, quickly turned to how to implement the recommendations, including how to empower families to challenge physicians or nurses when they see these steps being taken in the care of a loved one.

The Society for Critical Care Medicine, which sponsored the Congress, collaborated with the American College of Chest Physicians, the American Thoracic Society, and the American Association of Critical Care Nurses to create the list. It’s the first Choosing Wisely list to include collaboration with a nursing organization and only the second that’s a product of collaboration instead of being issued by a sole medical society, said Dr. Scott D. Halpern of the University of Pennsylvania, Philadelphia, chair of the collaborative group.

The four groups – the Critical Care Societies Collaborative – started with a list of 58 medical practices that they found objectionable, which they trimmed to 9 items based on the strength of evidence and their prevalence, relevance, and cost, explained Dr. Wunsch of the department of anesthesiology at Columbia University Medical Center, N.Y. Discussion winnowed that to the Top 5, an arbitrary number selected by the Choosing Wisely campaign that everyone should recognize as "a starting point," she said.

A two-page document of the critical care list can be downloaded from the Choosing Wisely website. It includes some of the sources for the recommendations and these top five "don’ts" displayed on the front:

1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions. Ordering diagnostic studies such as x-rays, arterial blood gases, blood counts, blood chemistries, or ECGs daily or at routine intervals drives up costs, doesn’t benefit patients, and may harm them through radiation exposure, inducing anemia, or triggering aggressive follow-up of incidental results. "I think this has become more prevalent with electronic medical records," where one click can order x-rays for the next 5 days, she said.

2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL. Blood is a scarce resource, and studies show that limiting red blood cell transfusions to thresholds of 7 mg/dL or higher does not worsen survival, complications, or costs, and causes fewer complications. Different thresholds may be appropriate for patients with acute coronary syndrome, but even in this subgroup aggressive transfusion is harmful, most observational studies suggest.

3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay. Early parenteral nutrition is harmful, even in patients who cannot tolerate enteral nutrition, if they were adequately nourished prior to ICU admission. The evidence is less clear for patients with nosocomial infections, and early parenteral nutrition may benefit patients who were severely malnourished right before ICU admission.

A study to be published soon shows that 90% of parenteral nutrition in the United States starts within 7 days of admission, usually within the first 2 days, Dr. Wunsch said. "It’s definitely more prevalent than I think many of us realize," she said.

4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Deep sedation of patients on mechanical ventilation prolongs the duration of ventilation and hospitalization. Several protocols for limiting sedation have been shown to improve patient outcomes.

5. Don’t continue life support for patients at high risk of death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort. When an audience member expressed concern about discontinuation of life support possibly increasing premature deaths, Dr. Wunsch stressed that the second part of the statement is key – giving the family the choice of comfort care or continuing life support.

The simplicity of the Choosing Wisely list and its focus on overuse and costs make it possible to pursue unconventional ways of making it widely adopted, such as empowering families to question care, said Dr. Jeremy M. Kahn of the University of Pittsburgh. The 5 recommendations are far fewer than the 85 recommendations in the 2002 Surviving Sepsis campaign, for example, and the Choosing Wisely campaign has partnered with Consumer Reports and engaged the lay press to help spread the word, he said.

Dr. Kahn described a recent uncomfortable experience in which he had to question some of the medical care being offered to a hospitalized family member. It wasn’t easy to speak up, even though he’s a physician, and it must be even harder for lay people, he said. Hanging a sign in every ICU with the Choosing Wisely list might help empower families to speak up, one physician suggested during the discussion.

Incorporating decision-support prompts in electronic health records also could help physicians adhere to the Choosing Wisely recommendations, Dr. Kahn said.

Beyond the five items that made the Choosing Wisely list, the four runners-up were issues of antimicrobial duration; CT or MRI scanning for altered level of consciousness; vascular catheter indications; and ICU admission criteria for patients with poor prognosis, Dr. Wunsch said.

The Critical Care Societies Collaborative represents approximately 150,000 critical care providers, according to Dr. Curtis Sessler, president-designate of the American College of Chest Physicians.

The Choosing Wisely campaign, a project of the ABIM Foundation, released lists of "Five Things Physicians and Patients Should Question" by 9 medical societies in April 2012 and 17 more in February 2013, with the development of more lists ongoing.

The speakers reported having no financial disclosures.