Critical Care Medicine Over the Years

Jamshed  Sunavala

SECTION 1

1History

Critical Care Medicine Over the Years

Jamshed Sunavala2

Critical Care Medicine Over the YearsCHAPTER 1

Jamshed Sunavala

INTRODUCTION

Medical history is vague about the exact time when critical care medicine as we understand today, began. However, the practice of caring for critically ill patients is not a new concept and does not differ greatly from the past. From the time of Hippocrates to Galen to Florence Nightingale and to the present times, the watch words have remained the same—vigil, speed, support, and compassion. These four pillars that constitute the spirit of critical care were also practiced by good old physicians and family friends—Luke Fildes painting of the country doctor says it all (Fig. 1).

In the further discourse, I have no intention to elaborate on the history of medicine—there are better books available on the subject. My main objective is to firstly acknowledge the men and women whose contributions over the years have made it possible for the standards of critical care accessible today and secondly, to understand the many limitations and inadequacies in our present approach to critical care medicine.

Fig. 1: The Doctor, exhibited in 1891, Sir Luke Fildes. Presented by Sir Henry Tate, 1894.Photo: Courtesy Tate

HIPPOCRATES

The physician from the island of Kos revealed for posterity the face of impending death—“The Hippocratic Facies”. He also observed the respiration 4of a patient with high fever, akin to that of a “man recollecting himself whilst breathing large and deep”—here possibly he was describing a case of severe sepsis in respiratory failure. Much before John Cheyne and William Stokes (both Scotsmen) were historically linked together to describe “Cheyne–Stokes breathing”, the notable gasp from a failing respiratory center was already described by Hippocrates as vividly as we see today—“gasping irregular breathing which would cease quarter of a minute and restart, first slow then heavy and fast and cease again”. He also commended all physicians caring for the critically ill, who conducted the treatment better than others. The present day intensivists seem to have taken him too seriously and are appalled by the mention of “open intensive care units (ICUs)”.

AFTER HIPPOCRATES

Indeed there is a long line of pioneers in the medical field following Hippocrates without whom we may have required another century or probably more, to be able to achieve today's modern science of critical care medicine. Celsus provided us with the signs of inflammation—“calor, rubor, tumor, dolor”. Anatomy was relatively nonexistent till the 16th century and the coming of Andreas Vesalius and his artistic anatomic atlas. June of 1543 saw two cherished works of the European Renaissance, one—“On the Revolutions of the Heavenly Spheres” a monumental work by Nicolaus Copernicus, and the other—“De Humani Corporis Fabrica Libri Septem” by Andreas Vesalius on the fabric of the human body. This masterpiece by Vesalius was illustrated by no other than Titian and his school of artist in the city of Padua. Till this time and for the previous 14 years, the gospel of Galen was considered the Bible of Medicine. Vesalius adored Galen, but he soon found discrepancies with Galen's manuscripts showing the anatomy of the human body which were at odds with his findings. He initially refused to believe this and he even entertained the theory that the anatomy of the human body had changed over the years, but when Galen's shortcoming became glaringly obvious, he realized that the great God of medicine had erred. It was Vesalius again in 1555 who first described the possibility of inserting a tube or a reed in an opening made in the trachea and blowing into it and thereby inflating the lungs. However, it was Paracelsus (1493–1541) who first demonstrated a type of assisted ventilation through a tube inserted in the patient's mouth. Interestingly, Vesalius who was wrongly accused by his enemies, was sent on a pilgrimage to the Holy Land as punishment for dissecting a Spanish Nobleman who they claimed, stirred on application of the scalpel and some went as far as to blame him for dissecting the body on a beating heart. During this voyage he was shipwrecked and died of hunger on the Greek Island of Zante (Zakynthos).

Robert Koch and Louis Pasteur dispelled Pettenkofer's belief of “miasma” or vapors being responsible for disease and were the first to identify the microbial agents as cause of infectious diseases. Florence Nightingale introduced a triage 5system for the critically ill wounded soldiers of the Crimean war. Drinker's Iron Lung and Fleming, Florey, and Chain's discovery of penicillin, the double helix of Watson and Crick and many others with their discoveries were the first to sow the seeds of what we reap today. However, the unbelievable advances in technology in the field of critical care medicine and progress in the last 60 years cannot be denied. The first attempt at using a positive pressure ventilator was during the polio epidemic in Europe in the early fifties. This period is probably the beginning of the modern concept of an ICU as we understand today.

POLIO EPIDEMIC OF COPENHAGEN

The polio epidemic struck Copenhagen in 1952. Bjorn Ibsen, an anesthetist, was consulted because the negative pressure iron lung was not helping the victims, though theoretically the bellows function of the iron lung, pushing air in and out, should have sufficed for the polio-afflicted patients who suffered from type II respiratory failure. Ibsen, to his surprise, observed increased blood levels of CO₂ reflecting persistent uncorrected respiratory acidosis despite being ventilated on the iron lung and obliviously concluded that the patients were inadequately ventilated and oxygenated. He improved the system by introducing positive pressure intermittently (through a tracheostomy), and in synchrony with the negative pressure phase provided by the iron lung. His crude, but effective method of providing the positive pressure intermittently [intermittent positive pressure (IPP)] was by introducing a Bennett's positive pressure valve in line with the continuous positive pressure applied from the other end. This supplemented positive pressure worked and substantially improved survival. Later the improved version of this contraption/device was also helpful in patients with primary type I respiratory failure with intractable hypoxemia by keeping the collapsed alveoli open, and this was the earliest mode of recruitment attempted and the rest is history. I believe that this period of the early 50s was the beginning and the first step to the multidisciplinary ICU of today.

THE TWO VITAL INTERVENTIONS THAT MADE THE DIFFERENCE

Respiratory Support

Respiratory, hemodynamic, nutritional management, and nursing are the four supports on which all critically ill patients depend on during the life-threatening phase of their illness. However, the first two have made a stronger impact as major supports in improving outcomes. After Ibsen's innovation of the IPP ventilator, more refined volume-cycled ventilators were developed by the mid-50s—these included the Bang and Engstrom ventilators, soon followed by Bennett MA-IB. With time, more sophisticated ventilators entered the market with various modes mainly used for lung recruitment and weaning. The most vital and universally used mode is the concept of positive end-expiratory pressure (PEEP) which followed the observation of Furman that when the exhalation limb of the circuit from the tracheostomy was inserted under 61–4 cm of water, it provided expiratory resistance and improved oxygenation by opening the collapsed alveoli and increasing the functional residual capacity (FRC). PEEP is today a standard mode used in most patients and has proved enormously successful in ventilating patients with ARDS. Barach's study describing the use of positive pressure respiration for treatment of pulmonary edema preceded Ibsen and was published in the Annals of Internal Medicine in 1938, however the emphasis was on providing positive pressure without intubation, as ventilation was not the prime concern. Two other historical landmark papers, which completely revolutionized the future of mechanical ventilation, were Ashbaugh, Bigelow, and Petty's publication on acute respiratory distress syndrome (ARDS) in Lancet 1967 and later the ARDS Network Study in New England Journal of Medicine (NEJM) 2000, stressing on the use of low tidal volumes in ARDS. It is remarkable that this (lung protection strategy), is the only mode that has shown significant survival benefit.

Hemodynamic Support

William Harvey's “De Motu Cordis” published in 1628, detailed the circulation of blood and he can rightly be called the father of hemodynamics. However, the complete pathway for circulation was identified half a century later by Marcello Malpighi, also famous for his discovery of capillaries connecting veins to arteries. The English clergyman Stephen Hales crude 4 feet glass tube inserted into the artery of a horse in 1733 was of course too cumbersome for our modern ICUs, but thankfully the Austrian physician Karl Samuel Ritter von Basch designed the first portable sphygmomanometer in 1881. He claimed haughtily that cutting open a patient's artery would no longer be required, but had he lived a century longer, he would have been quite disappointed to note that we puncture open radial arteries a bit too enthusiastically in our ICUs today. Till the turn of the 19th century, one could measure only systolic blood pressure and it was only in 1905 that Nikolai Korotkoff was able to measure diastolic pressure by identification of certain sounds, now known as Korotkoff sounds.

The modern concept of hemodynamics as we understand today can be credited to John Womsley (1907–1958) and Donald McDonald (1917–1973). McDonald's thesis on “Blood Flow in Arteries” has since been a standard work in the field of hemodynamics. The Nobel prize in medicine for performing the first right heart catheterization in a human went to Werner Theodor Otto Forssmann who inserted a urethral catheter in his own basilic vein and advanced it into the right heart, when he was only a 25-year old surgical resident. He was dismissed from the hospital for his reckless act in attempting such a suicidal experiment and disrespecting the reputation of his department. We are not certain as to which department took umbrage, whether it was cardiology or urology. Later Drs Andre Cournard and Dickinson Richards innovated new catheters which could be advanced into the pulmonary arteries and they joined Forssmann in receiving the Nobel Prize in 1964. However, it 7was not until Jeremy Swan and William Ganz invented the balloon floating pulmonary artery catheter (PAC) for measurement of right-sided pressures that opened the possibility of bedside hemodynamic monitoring. Unfortunately, this catheter gained instant notoriety after the moratorium decreed by no other than Dr Roger Bone at the end of the last century. Today intensivists who rail against the use of Swan-Ganz catheters should remember that “any tool can be a weapon in the wrong hands”. Fluid resuscitation now followed the adage that “cardiac filling pressure is not fluid responsiveness”; dynamic values of stroke volume variation (SVV) and pulse volume variation (PVV) are now considered appropriate, and just measuring pulmonary wedge pressure as an index of left ventricular filling pressure may not always reflect the improvement in the cardiac output to volume challenge. To understand this subject, it would be well to refer to a landmark paper in Clinics in Chest Medicine, 2003 on hemodynamic monitoring by Michael Pinsky.

Methods of supporting patients with severe cardiogenic shock or refractory cardiac failure have made considerable strides in the last two or three decades with newer inotropes, but more significantly due to better understanding and application of both inotropes and vasopressors already in use. Introduction of intra-aortic balloon pumps (IABPs) and newer ventricular assist devices such as the Impella device have contributed immensely for bridging patients to interventions, surgery, or even to conceivable recovery. Adding extracorporeal membrane oxygenation (ECMO) to the Impella (ECPELLA) can help patients with cardiac and respiratory failure with refractory hypoxia.

GENESIS OF TODAY'S INTENSIVE CARE UNITS

The concept of close monitoring of the critically ill was first conceived by Florence Nightingale during the Crimean War in the 1850s. She was also possibly the first to arrange and separate the sick according to the severity of their illness, keeping the ones who required close monitoring nearest to the nursing station, a concept that we call “Triage” today. In 1923, Walter Dandy opened a separate three-bedded unit for critical postneurosurgical patients at the Johns Hopkins Hospital in Baltimore, USA. By the 1930s, many such postoperative recovery rooms for close monitoring and observation, mushroomed during the Second World War and special shock units to provide the best resuscitation facilities, were setup on the fronts. 1958 saw the first modern prototype of a multidisciplinary ICU at Baltimore City Hospital, USA, under Dr Peter Safar and soon hospitals all over USA and Europe adopted the same plan for their ICUs.

In India, most of the hospitals till the early 70s were designed to look after critical cardiac patients and called them intensive cardiac units. They exclusively looked after the patients with coronary artery disease and their main purpose was to closely monitor arrhythmias requiring immediate cardioversion or pacing, and in the event of an arrest, to resuscitate. But there was little facility available to support over time, patients with organ failure. 8Quoting Dr FE Udwadia's introductory lines from the preface of his Textbook of Critical Care Medicine, “……. these units, though centralized were designed and equipped chiefly to offer intensive care to patients with acute myocardial infarction. Mechanical ventilation was primitive; its use being mostly restricted to token gesture of graces offered to a patient about to depart from the world”.

The concept of advanced respiratory and hemodynamic support developed post availability of good positive pressure ventilators together with facilities to monitor hemodynamics at the bedside along with the availability of Swan-Ganz catheters.

However, our main challenges in India today are the lack of ICU beds, poor patient-to-nurse ratios, lack of excellent training facilities, and affordable treatment.

Battle of the Bugs

Bacteria have lived and owned the world billions of years before us and perhaps we live here only because they allow us to, but definitely we could not survive without them. The ones in our gut help to fight foreign microbes, which could otherwise make us sick. They divide and breed but once every million divisions they may mutate and the mutant bacteria may have an added advantage of being resistant to antibiotics. Antibiotic resistance can of course occur in many ways, mainly because of overuse and abuse and consequently we are faced with the dreadful dilemma of multidrug resistance (MDR) and pandrug resistance (PDR). Drug resistance, with no new and effective antibiotics in sight, has become the greatest predicament we face in our ICUs today.

Increasing population of elderly patients in our ICUs with diseases and drugs, which suppress their immune system, are at the biggest risk of developing serious infections. In most cases our immune system fights back, but not before unleashing a cytokine storm from a dysregulated host response to infection, which leads to life-threatening organ failure. Sepsis was defined in 1992 by Roger Bone and colleagues as a systemic inflammatory response syndrome (SIRS) but now the latest definition of 2016, Sepsis-3, is all about organ dysfunction.

ERA OF ORGAN TRANSPLANT AND IMMUNOSUPPRESSANTS

The earliest attempts in human transplant were done in India almost a thousand years ago; of course, what described were not organ transplants but autotransplant of flaps. The first attempt at human-to-human kidney transplant was done by Dr Yu Yu Yuronoy in 1936 which failed in the early postoperative period due to rejection. However, the credit to the first successful kidney transplant goes to Dr Murray and his team from Boston in 1954 and it was performed between identical twins. On the other hand, it was not till late 60s that several successful liver transplants were done where all patients received immunosuppression with azathioprine and cortisone though none survived beyond 23 days.9

It was not until the discovery of cyclosporine, refinement of surgical techniques and donor supports that both kidney and liver transplant were no more considered experimental but seriously offered as therapy. By the early 1990s the introduction of tacrolimus, which has a greater potency than cyclosporine, paved a way for longer survival. Further, advance in organ procurement and preservation and newer immunosuppressants following the calcineurin era has made organ transplant (especially kidney and liver) a routine surgical procedure today with a high success rate.

The increasing organ transplant program and the large gamut of immunosuppressants in use have created an enormous burden on the ICU. The intensivist today has to deal with early and in-hospital post-transplant complications and they need to be conversant with the drugs and their various side effects ranging from hematological complications following the use of azathioprine, mycophenolate, sirolimus, and antibodies (monoclonal and polyclonal antibodies). Cyclosporine has side effects on the kidney and heart whereas tacrolimus in addition to the side effect on the kidney also has central nervous system (CNS) toxicity. The newer class of immunosuppressants such as belatacept is relatively safe but a few cases of post-transplant CNS problems such as an increased risk of multifocal leukoencephalopathy and post-transplant lymphoproliferative disorder have been described with its use. To further compound the work of the already stressed ICU staff is the use of steroids causing new-onset diabetes mellitus with uncontrolled high sugar levels. Patients on immunosuppressants also present in the ICU with perplexing problems, especially fever of unknown etiology and most of these medications have unique interactions with the commonly prescribed adjunct agents such as antibiotics, antifungals, antihypertensives, and antidepressants. Despite progress, the future of transplant holds a lingering fear of alarming zoonotic transmitted infections such as the Ebola virus, etc., with the ongoing experimental trials of xenotransplantation.

It was not until 1980 that a lung transplant with an acceptable outcome was achieved by Joel Cooper and Colleagues. However, the overall survival rate even today is approximately 50% at 5 years. Despite major advances, complications of post lung transplant are not uncommon. Bronchial stenosis at the anatomic site and unexplained noncardiogenic pulmonary edema within 72 hours following transplant and wide spectrum of infections are the main complications that the intensivist may have to deal with in the first or second week post-transplant. The first cardiac transplant was successfully performed by Christiaan Barnard in 1967. Now heart transplant has become a standard surgery for treating patients with advanced and refractory heart failure. In the majority of patients, the immediate postoperative course would be similar to post bypass surgery requiring ventilatory support and management of possible arrhythmias. Rejection and problems of immunosuppression are usually experienced later. However, the intensivist should be on guard to deal with immediate surgery-10related infections and well versed with management of advanced support such as IABP and temporary left ventricular assist device (LVAD).

EVIDENCE-BASED MEDICINE

As doctors, most of us must have read AJ Cronin's “The Citadel” written in 1937, which became the moving spirit behind the foundation of the National Health Service (NHS) in Great Britain. The man behind the main theme of the novel was Dr Mason, whose management of patients was based not only on his skill as a doctor with independent thinking but also on uncompromised and sound ethical principles. I am not sure how well he would have fared in today's time where he would have to abandon his lateral thinking and diagnostic skills developed through experience, and now compelled to restrain his personal views and act in accordance with the evidence of others, strictly adhering to protocols and bound by technology.

Very often evidence was based on a single trial and discarded by another to become invalidated. This has been revealed by retrospectively reviewing, a vast body of literature published in the last 30–40 years from which we have learnt that single-centered randomized controlled trials (RCTs) have failed often by not being replicated in larger multicentered RCTs. A typical example is the strongly advocated early goal-directed therapy (EGDT) of River's published in NEJM in 2000, a single-centered RCT confirming a survival benefit that was not substantiated in later studies. This shows that guidelines will change with newer and better controlled trials hence a single study from one center should not cloud one's judgment.

Evidence, besides providing useful guidelines, has also given us insight into certain aspects of bedside care that were considered perfunctory. For instance, early intubation is beneficial for critically ill patients; also, head elevation to 30° and improved oral hygiene decreased incidence of ventilator-associated pneumonia (VAP). It was helpful, among many others, in formulating guidelines such as the surviving sepsis campaign and septic bundles and glycemic control protocol. Probably the greatest benefit evidence-based medicine (EBM) revealed was the importance of teamwork for more efficient ICU functioning.

END-OF-LIFE CARE FOR THE TERMINALLY ILL

In general, the patient population admitted to ICUs today is older than they were 40 years ago. This means greater morbidity for obvious reasons and many elderly patients with comorbidities succumb to a critical illness. A few, pull on, with the help of cardiopulmonary support till they are labeled terminally ill with little hope of complete recovery and many have no meaningful existence even after a protracted recovery period. The other group of patients, young or old, are those who have survived a successful resuscitation but with a very dismal outcome. Less than a quarter survive to discharge and of these only a handful have a meaningful recovery. Hence, it behoves that the treating doctor to deal with 11both the patient and the family with responsibility and utmost sensitivity, but sooner or later the sensitive issue of do not resuscitate (DNR) will be brought up.

Before considering DNR, repeated counseling of the family members is essential and discussions should include an honest picture of the patient's functional status and prognosis of future outcome. Relatives’ preferences should be carefully understood and sympathetically considered, before pronouncing views regarding futile resuscitation. The counseling doctor has to be well aware that often our ability to prognosticate the outcome may not be perfect. Hence, using phrases such as “meaningful existence, morality issues, and dignity in death”, may often carry a certain degree of arbitrariness and should be used carefully, sensing the poignancy of the moment, even though the family has accepted the inevitable. Further, avoid using a self-fulfilling prophecy to coerce the patient into accepting DNR.

With organ transplants on the rise, the modern ICUs have to contend with the ethics of certifying brain death for organ donation. Mollaret and Goulon in 1959 were the first to describe death based on the loss of function of the brain. Guidelines for determination of brain death have been framed by multiple scientific committees, to instruct clinicians to accurately examine patients, to avoid risk of diagnostic error and legal implications. It is important to remember not to callously disregard the last hope of living, which every family desires, so be thoughtful before pronouncing “futile resuscitation”.

Four centuries ago, Francis Beacon defended the art of reasoning by general and liberal education of all humanities and advised not to lose our perspective only in the worship of science. This promoted a wise judgment of ends to accompany the scientific improvement of means. His words seem more applicable to our times, with an increasing population of the terminally ill, taxing our reasoning and judgment.

CORONAVIRUS DISEASE-2019 PANDEMIC: THE INDIAN SCENARIO

The ongoing pandemic of coronavirus disease-2019 (COVID-19) infection has created a serious impact on the future of our understanding of viral infections. It has opened a new perspective on the physiological and immunological aberrations, responsible for the varied clinical manifestations and complications that has thrown light on the therapeutic implications of the drugs and interventions used. The intensivists particularly have struggled to improve outcomes of the critically ill and many new challenges and predicaments have been an eye opener.

The COVID-19 pandemic spread worldwide in 2020 and continued to rage even through 2021. The pandemic was caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and was first reported in December 2019 from the Wuhan provenience of China from where it originated, but the first case reported in India was on 30th January 2020. At the time of writing 12this book (May 2021) India was in the midst of a second wave of COVID-19 pandemic and by now has had the second largest number of confirmed cases (after the United States), with 26 million reported cases and over 3 lacs deaths. This second wave advanced with enormous casualties which was far more devastating than the first wave in September 2020 and the experts predicted a catastrophic rise of COVID-19 infection with a mounting death rate by the end of this surge. The magnitude of the second wave left India totally unprepared with shortage of hospital beds, oxygen, ventilator, vaccines, and drugs, more- so in the rural areas. Multiple factors were proposed for this unprecedented surge, including a rampant disregard to personal protection by the public. People let lose their guard, soon following the first wave with the incidence of COVID showing a dramatic decline in comparison to other countries. This self-assured hubris among the public and the government, led to complacency resulting in relaxation of preventive control measures.

In consistency with current chapter, it is relevant to discuss those serious cases requiring ICU care. Critically ill patients of COVID presented with a myriad complications, which are otherwise seen rarely in one disease. Patients during the onset of the pandemic throughout the first wave presented in the ICU with a clinical picture suggestive of ARDS and likewise the management guidelines were prototyped to correction of refractory hypoxia and prevention of alveolar capillary leak. However, with time many features of respiratory affliction following COVID were at odds with that of ARDS as known to us. Firstly, many patients tolerated oxygen desaturation (even below 90%) without displaying any signs of respiratory distress. Secondly, during the very acute phase there was no evidence of refractory hypoxia as most cases of severe oxygen desaturation (well below 90%) were corrected with nasal oxygen delivery of 2–4 L/min and this was out of line with the very definition of ARDS. With time, majority (over 95%) of these patients recovered but of which only few required ventilator support and here too most responded to noninvasive ventilation (NIV) or high-flow nasal oxygen (HFNO). Though ground glass appearance on the chest CT was common with ARDS, the distinctive appearance of peripheral pneumonia hinted in favor of COVID. The confidence of managing hypoxia without ventilatory support conveniently favored home management in mild-to-moderate cases, especially during the second wave, when there was an acute shortage of hospital beds.

The few with refractory hypoxia went from NIV to intubation and mechanical ventilation and had high mortality rates and even with the best of ICU care, almost over 60% did not make it to recovery. ECMO was the last resort for refractory hypoxia and though the outcome was very poor, it was offered to the younger population mainly on compassionate grounds. The only therapies that showed benefit in serious cases of COVID were:

Oxygen with or without mechanical ventilation
Prone positioning13
Steroids—dexamethasone 6–8 mg per day or methylprednisolone 40 mg twice a day to be used judiciously
Anticoagulants—low-molecular-weight heparin (LMWH) or oral anticoagulants (apixaban 2.5 mg twice a day)
Interleukin-β (IL-β) inhibitor tocilizumab available in the market as “Actemra”.

Timing of giving the above medications was of paramount importance—too early may be ineffective or even harmful at times and too late was like offering the last ministrations to the dying. Steroids for instance was a case in point. Tocilizumab used in patients without ruling out underlying bacterial or fungal infection can lead to life-threatening septic shock. At the same time, it should be cautiously used and timed before patient becomes terminally ill with a full-fledged cytokine storm and on ventilator/inotropic support.

Thromboembolic complications emerged as an important issue in patients with COVID-19 infection. They were due to a procoagulant pattern and very likely related to an endothelial thromboinflammatory syndrome and the common complications emerging from this syndrome were pulmonary embolism and cerebrovascular accidents. Hence, appropriate use of anticoagulants was advocated with worsening of symptoms even at times prior to hospitalization.

Since the first wave much has happended and by the time second phase reached its peak many unusual complications were recorded. Though acute respiratory failure with refractory hypoxia was the leading cause of death other unexpected fatal complications were recorded. These included:

Cardiac failure: Here uncertainty remains whether the virus was directly causing myocarditis or the cardiac damage was secondary to the severity of the illness.
Secondary infections: Bacterial and bloodstream infections were commonly seen. However, fungal infection of the lung such as aspergillosis and mucormycosis were not that uncommon in the sickest of the patients.
Acute liver injury and liver failure occurred rarely but was very sudden with a high mortality. It was not certain whether this was a result of direct harm from the virus or other antecedent causes.
Acute kidney injury (AKI) seemed to be a common complication secondary to the hemodynamic and respiratory compromise in the severely ill cases. Most of them recovered from AKI with improvement in their respiratory and cardiac function but some of the cases did require hemodialysis.
Disseminated intravascular coagulation (DIC) leading to undue clotting or bleeding occurred mainly in the critically ill patients or during a cytokine storm or associated with severe sepsis.
Pneumomediastinum and pneumothorax as complications were seen in the critically ill patients with COVID infection and not necessarily in ventilated patients. The worse sequelae to this were bronchopleural 14fistula, which could lead to a protracted stay in the ICU and very often a poor outcome.

The second wave of COVID-19 showed progressive worsening in most parts of India taking a high toll on life and economy. Lockdown periods had been extended in most parts of India, though in certain regions such as Mumbai, some evidence of plateauing was emergerging by July 2021. Lately the use of monoclonal antibody cocktail (casirivimab + imdevimab) which mirrors human antibodies was found to be useful in thwarting the infection in the early phase of the disease. Its use is mainly restricted to mild-to-moderate high-risk symptomatic patients (before the requirement of supplemental oxygen) where it was found to be most effective.

Perspective and Conclusion

I would like to end this chapter by stressing on the human aspects of critical care which seems to be lost in the midst of advanced technology, invasive therapies, slow erosion of clinical medicine and the influence of the corporate health care structure today. In the near future, I fear that ICUs may become a brutal place for patients, relatives and the care givers. For the patient it might mean dehumanization of the individual, relatives will be considered mere customers in the waiting room and the patients families will be constantly under stress of escalating cost with unpredictability of prognostication. Doctors and nurses may lose their clinical acumen and remain vulnerable despite the availability of high-tech imaging, integrated monitoring systems and the limitations of the many lifesaving machines.

Modern technology may be considered as a triumph for medicine but at a staggering cost, if it prolongs lives only to confront us to a new form of misery. Thus medicine may turn into a meaningless exercise, once it is realized that therapy meant to heal has only bought more time to be ill. The future raises the daunting possibility of an industrial or a corporate model evoking image of an ‘assembly line’ management of health care . For this not to happen we need to answer the all important question – “Whether a world without disease is possible”. If not, then the medical profession has to hone their skills and change current prospectives that will allow the doctors to preserve and augment their clinical acumen, judgment and humanity.

How do we put all these problems in place so that it can be managed in a more civilized manner? At the outset, we need to recognize that we are slowly dehumanizing the intensive care unit. Better communication skills should be the essence of critical care training in order to assuage a stressful encounter for patients and relatives in and out of the ICU. Technology should be used as an aid and not a replacement for clinical skills and judgment. It is imperative to understand that doctors and nurses are mere humans and they too have personal fear of death, conflicting religious and personal convictions, untoward experiences with patients, constantly battle with feeling of remorse, guilt and peer pressure. All these can result in a “Burn-out” syndrome.15

Thus critical care is a blend of vigil, speed, skill, compassion and care balanced and supported by the use of five senses - without which all technology is virtually useless.

Chapter Notes

Critical Care Medicine Over the YearsCHAPTER 1