Asia Pacific Journal of Pediatric and Child Health

Ref Number = ASPR0049

Promoting Value in Critical Care by Practicing ?Less is More?

Antonius H. Pudjiadi
Child Health Department FKUI-RSCM, Jakarta

Over the last 30 years, critical care medicine dramatically decreases mortality of the patients. However, with amazingly large healthcare expenditures, the survivors have a lower quality of life because of their cognitive, emotional and physical sequelae.1-3 
 
Many studies that have been marked as a ?strong evidence?, and used for developing guidelines, nowadays interpreted differently. Marik and Bellomo argued the sacred Starling?s law, and the shocking River?s Early Goal Directed Therapy, by showing the effect of fluid on extravascular lung water.4,5 Gattinoni and Pasenti came with the baby lung concept that provides a gentle lung treatment to prevent baro- and volutrauma.6 Amato et al. have done a post hoc analysis data from the ARDSNet-trial, and showed that tidal volume target alone can be misleading.7,8 Recently, a large randomized controlled trial by Girard et al. suggest that daily awakening (interruption of sedative) with daily spontaneous breathing trials result in better outcomes for mechanical ventilated patients than current standard approaches.9 

Overused of fluids and drugs, in the ICU, caused an altered consciousness, delirium and prolonged mechanical ventilation. Over the past 20 years, many investigators focus on patient comfort and safety issues in the ICU related to pain, sedation, delirium (PAD), and early mobility, evolving to a bundle of care.10-12 The ABCDEF bundles consist of the awakening and breathing coordination of daily sedation and ventilator removal trials, delirium monitoring and management, and early mobility and assessment, prevent and manage pain, both spontaneous awakening and spontaneous breathing trials, choice of analgesia and sedation, assess, prevent and manage delirium, early mobility and exercise, family engagement bundles are part of the science of the liberation of the intensive care unit.  Implementing the ABCDEF bundle showed a significant improvements in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions and post-ICU discharge disposition (destination other than home among survivors).13,14

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