Gopalratnam Kavitha, Forde Inga C, O'Connor Jaclyn V, Kaufman David A
Department of Internal Medicine, Bridgeport Hospital/Yale University School of Medicine, Bridgeport, Connecticut.
Section of Pulmonary, Critical Care & Sleep Medicine, Bridgeport Hospital/Yale University School of Medicine, Bridgeport, Connecticut.
Semin Respir Crit Care Med. 2016 Feb;37(1):23-33. doi: 10.1055/s-0035-1570358. Epub 2016 Jan 28.
The intensive care unit (ICU) was initially developed in the 1950s to treat patients who required invasive respiratory support and hemodynamic resuscitation. Since the beginning, ICU medicine has focused on maintaining sufficient arterial blood flow and oxygenation to provide adequate tissue oxygen delivery to forestall or reverse organ failure. Over time, ICU medicine became more intensive, with the administration of many diagnostic tests and monitors, invasive procedures, and treatments, often with scant evidence of benefit associated with them. An alternative perspective holds that ICU patients may represent a group of patients that is especially vulnerable to iatrogenic harm. We outline a case that presents common ICU dilemmas and discusses current data that propose that "less is more" when making key diagnostic or therapeutic choices in the ICU. Further, we assert that providers should skeptically consider common ICU interventions, trying to account for the potential unintended consequences of interventions. Finally, we suggest that the guiding principle of ICU medicine should be primum non nocere: in delicate situations, it may be better not to do something, or even to do nothing, rather than risk causing harm.
重症监护病房（ICU）最初是在20世纪50年代设立的，用于治疗需要有创呼吸支持和血流动力学复苏的患者。从一开始，重症监护医学就专注于维持充足的动脉血流和氧合，以提供足够的组织氧输送，防止或逆转器官衰竭。随着时间的推移，重症监护医学变得更加精细化，进行了许多诊断测试和监测、侵入性操作及治疗，而这些往往缺乏与之相关的获益证据。另一种观点认为，ICU患者可能是一组特别容易受到医源性伤害的患者。我们概述了一个呈现常见ICU困境的病例，并讨论了当前的数据，这些数据表明在ICU做出关键诊断或治疗选择时“少即是多”。此外，我们主张医疗服务提供者应持怀疑态度考虑常见的ICU干预措施，尝试考虑干预措施可能产生的意外后果。最后，我们建议重症监护医学的指导原则应该是“首要的是不伤害”：在微妙的情况下，不采取行动甚至什么都不做，可能比冒险造成伤害更好。
