Lim: Understanding global critical care

Clinical Pearls (Outline provided by Dr. Andrew Lim)

• Global health and critical care can be united because:
  • “At its core, critical care is simply healthcare for very sick patients”… “The care of the critically ill patient is a global enterprise.” (Elizabeth Riviello, MD)
• Three major pillars:
  1. The timely recognition and stabilization of critical illness
  2. Access to and delivery of critical care
  3. The definitive management, recovery, and rehabilitation of the critically ill
• Global critical care is applying these foundations of critical care to areas of the world without the resources we are accustomed to.
  • Recognizing the extent of critical illness where complex monitoring doesn’t exist.
    • The industrialization and evolution of Low and Middle Income Countries (LMICs) is rapidly changing:
      • A disproportionate amount of the critically ill are in LMIC, where there is poor access to and development of critical care resources. (ATS 2013)
      • There is increased transmission of communicable diseases, with a staggering rate of deaths from sepsis – world rates about 5x that of High Income Countries (HICs), and rates in Sub-saharan Africa about 12x that of HICs.  (Lancet 2010)
      • There is a false assumption that these countries do not have the resources to perform critical care.

ATS 2013

• Four components to the strengthening of critical care systems in the developing world:
  1. Addressing Local Context and Population: 
     • The building of any critical care response system must take into account contextual factors, such as local politics, economics, and history.
  2. Management of Limited Resources: 
     • Huge disparity of MDs, nurses, and other healthcare providers between HICs and LMICs. (NEJM 2014)
     • Inadequate critical training of doctors and nurses in the clinical management of critical medical conditions
       • Sepsis representing the largest knowledge gap.
     • Difficulty in accessing a variety of ICU equipment, monitors, medicines, and blood products in LMICs compared to HIC counterparts. (J Intensive Care 2015)
     • There is a direct and positive relation between the amount of ICU capacity and healthcare dollars spent per capita. (PLoS One 2015)
       • Bosnian study showed that ICU care was ”very cost effective” compared to similar patients in other settings receiving floor care only. (World J Crit Care Med 2016)
  3. Regionally Focused Research: 
     • A one-size-fits all approach to critical care based on high income country research can fail in resource-limited settings.
     • Some examples where HIC research and assumptions fail in LMIC:
       • FEAST Trial: a multi-center RCT looking at mortality amongst pediatric populations with signs of sepsis comparing the effects of fluid boluses.
         • There was no significant impact between colloid or crystalloid boluses.
         • Giving resuscitative fluids was more harmful than a fluid restrictive approach overall.
       • The Kigali Modification of the Berlin criteria: utilized several individually validated replacements of the key Berlin criteria such as ultrasound and pulse oxygen sat/FiO2 ratio.
         • Identified a 4% prevalence of ARDS where 0% fit Berlin criteria.
         • Example that critical illness and critical care should be defined by the gravity of illness of a patient rather than the diagnostic and treatment modalities available.
  4. National & International Surveillance: 
     • The scaling up and unifying of broadscale interventions.
       • Requires the cooperation of national + international actors to create guidelines and best practice recommendations.
     • Simultaneously, we must allow for regional tailoring of interventions based on local research.
       • Involves national health ministries, university hospitals, district police, fire response systems, and public infrastructure departments.
     • Examples:
       • WHO interventions such as Trauma Care Checklist
       • Emergency Care Systems Framework (WHO Emergency, Trauma, and Acute Care Programme)
       • World Bank data on nosocomial surveillance
• In conclusion, Global Critical Care is without a doubt an essential field, as health systems must respond to the increasingly complex health needs of the developing world.