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Comment & Response
March 2014

Management of Critically Ill PatientsThe Less Intensive the Treatment, the More Vigilance Demanded

Author Affiliations
  • 1Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
  • 2Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
JAMA Intern Med. 2014;174(3):477. doi:10.1001/jamainternmed.2013.13686

To the Editor Intensive treatment strategies in critically ill patients have recently been challenged by Kox and Pickkers,1 who state that the chances of unwanted adverse effects and consequent iatrogenic damages are high and conclude that these patients would probably benefit from a more cautious approach; hence the expression, “less is more, not too intensive in ICU [intensive care unit] management.” The idea, at the first glimpse, is remarkable and worthy of further consideration. However, one should not overlook the fact that the nature of ICU is critical, and any reductions in vigilance, monitoring, and treatment intensity might lead to undesirable poorer outcomes. Lower values do not necessarily equate to less intensity in treatment, as decreasing tidal volume in patients with adult respiratory distress syndrome, fluid intake during resuscitation, and the duration of antibiotic therapy and changing sedation approach from continuous to intermittent would be associated with a more appropriate patient outcome, yet require more cautious and rigorous care and monitoring in critically ill patients. Implementing a high-intensity staffing model has been associated with significant improvements in the length of ICU stay and bed utilization of critically ill patients.2 Furthermore, reducing sedation and its associated consciousness might challenge the patient with undesirable thoughts requiring a narrative on the emotions and awareness throughout the ICU stay to avoid any probable posttraumatic stress disorders, often associated with long-term ICU stay.3 As with the critically ill patients requiring mechanical ventilation, high-intensity ICU structures have been reported to be of more favorable mechanical ventilatory outcomes and lower mortality rates.4,5 Critically ill patients require intensive treatment and in case any reductions in the treatment course intensity are intended, further vigilance would be inevitable; hence, the less intensive the treatment strategies, the more vigilant the caring system should be.

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