Chapter 84: Complications: Never Never or Never Ever

Hospitals are a dangerous place. Experts estimate that nearly 100,000 people die every year from medical errors that occur in hospitals, more than die from breast cancer, AIDS or car accidents. The ICU is especially challenging. There are multiple medical personnel including the primary ICU team and usually one or more consultants caring for patients. Critically ill patients are treated with multiple medications and often undergo procedures, thereby increasing the risk for adverse events and drug interactions. Recent trends in medical education have reduced the number of hours that house officers can work each week thereby increasing the number of handoffs, creating more opportunities for communication failures.

In this increasingly complex environment, there will be complications. The stakes are high. Complications increase morbidity and mortality in the critically ill. Furthermore, they erode public trust in physicians and the medical system as a whole. As a result, physicians may experience stress and loss of confidence in an increasingly complex medical system. One study estimated two serious errors per day for a 10-bed critical care unit. Medication errors accounted for 78% of the serious errors in this study.¹ Medical error is generally defined as the failure of a planned action to be completed as intended (eg, error of execution) or the use of a wrong plan to achieve an aim (eg, error of planning) and an adverse event as an injury caused by a medical intervention rather than the underlying condition of the patient.² A recent study reported 1,192 medical errors for 1,369 patients; 27% of patients experienced at least one medical error. Patients experiencing two or more adverse events had a threefold increase in overall mortality.³

The landmark report “To Err is Human” published by the Institute of Medicine highlighted the magnitude of the problem and the far reaching cost of medical error. The report heralded an era of patient safety and the development of quality initiatives for the care of hospitalized patients, especially patients in the ICU.² Critically ill patients are subject to intensive therapies that are most often associated with highest risk and therefore untoward events. This chapter describes common ICU complications and risk mitigation strategies.

Hospital acquired infections (HAIs) are a frequent complication of intensive care accounting for prolonged intensive care unit (ICU) length of stay, morbidity, suffering, and death. According to the Centers for Disease Control and Prevention (CDC), about one in every 20 patients will develop an HAI. Such infections were long recognized by clinicians as an inevitable hazard of hospitalization and are most often associated with invasive medical devices or surgical procedures.³

Central line associated bloodstream infections (CLABSI) are common in the United States accounting for nearly 100,000 bloodstream infections annually with half occurring in the ICU setting. While one third of these infections are attributable to gram negative organisms, other organisms like coagulase-negative staphylococci, Staphylococcus aureus, and enterococcus predominate. Host factors associated with increased risk for CLABSI include neutropenia, immunosuppression, total parenteral nutrition (TPN) use, chronic illness, and burn. Prolonged catheter use, conditions of insertion, and catheter site care also play a role in the development of CLABSI. For patients with suspected or confirmed CLABSI, the indwelling catheter should be removed and cultured with the institution of empiric antibiotic therapy. The initial selection of antibiotic depends on the severity of the infection, but generally vancomycin is used because of its activity against coagulase negative staphylococci and Staphylococcus aureus. Ceftazidime or cefepime may be needed for severely ill or immunocompromised critically ill patients.

Urinary tract infections account for more than 15% of infections reported by hospitals. Virtually all health care associated UTIs are caused by instrumentation of the urinary tract. A catheter-associated UTI (CAUTI) is a UTI where an indwelling urinary catheter was in place for more than two days. The majority of cases are caused by Escherichia coli followed by Pseudomonas aeruginosa, klebsiella species, and enterobacter species. Cefepime, ceftazidime, piperacillin-tazobactam, aztreonam, ciprofloxacin, and meropenem are generally first-line agents. In addition to sterile unobstructed closed drainage systems, prompt removal of urinary catheters is the single best strategy for CAUTI prevention.

Ventilator associated pneumonia (VAP) is a hospital acquired pneumonia that occurs 48 hours or more after the institution of mechanical ventilation. It is the most common nosocomial infection afflicting patients with respiratory failure and accounts for nearly half of all antibiotics used in the ICU setting. Nearly 20% of mechanically ventilated patients will get a VAP during their ICU course. VAP is caused when the normal host defense mechanisms are bypassed with the endotracheal tube and microaspiration of contaminated oropharyngeal secretions occurs. Rapid colonization of the oropharynx with gram negative bacteria occurs following antibiotic use and illness secondary to resultant compromise of host defenses such as ciliated epithelium, mucus, and glottis. Patients are unable to cough and the contaminated secretions pool above the endotracheal tube cuff and migrate along the airway. Biofilm, impervious to systemic antibiotics, forms along the endotracheal tube and serves as a breeding ground for bacterial growth which ultimately leads to infection.

The CDC National Healthcare Safety Network (NHSN) implemented a ventilator-associated events (VAE) surveillance program in 2013.⁴ This surveillance algorithm uses objective elements to identify complications associated with mechanical ventilation. VAP is included in the algorithm, which starts with the presence of a ventilator-associated condition (VAC), a period of respiratory deterioration following a sustained period of stability or improvement on the ventilator (eg, changes in PEEP or FiO₂). The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature (temperature > 38°C or < 36°C) or white blood cell count (WBC ≥ 12,000 cells/mm³ or ≤ 4,000 cells/mm³), and requires the initiation of a new antibiotic for treatment of presumed infection. The third-tier definition is probable VAP and requires that patients with IVAC also have purulent respiratory secretions or laboratory evidence of respiratory infection. For quantitative cultures, a bacterial density of at least 10⁶ CFU/ml for endotracheal aspirate, 10⁴ CFU/ml for bronchoalveolar lavage, and 10³ CFU/ml for protected specimen brush and for semiquantitative cultures, at least moderate growth of bacteria.

Risk factors for VAP include a supine position, previous broad spectrum antibiotic exposure, reintubation, acute respiratory distress syndrome (ARDS), prolonged mechanical ventilation, and trauma. The most common pathogens to consider for VAP are Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumonia, acinetobacter species, Streptococcus pneumonia, and Haemophilus influenza. Polymicrobial pneumonia is common and one should note that multi drug resistance is increasingly frequent in the ICU setting, particularly for patients with prolonged intubation, prior hospitalizations or ICU admissions, immunosuppression or those requiring hemodialysis. All ventilated patients without contraindications should be maintained in the semi recumbent position with the head of the bed raised 45° and be weaned from mechanical ventilation as soon as possible.

Hospital hand hygiene protocols have been shown to reduce the risk of certain HAI. The World Health Organization estimates that nearly 2 million patients each year are affected by poor hand hygiene practices in hospitals. A shocking number of health care providers fail to embrace hand hygiene. Healthcare workers should wash their hands for 15 to 30 seconds with soap and water or an approved alcohol based hand rub before and after patient contact.

Medication errors consistently make up the largest group of medical errors. Risk factors include the use of continuous intravenous infusions, polypharmacy with the potential for drug interactions and complex dosing regimens. Medication errors in one study were most commonly associated with treatment, but were also related to prevention (eg, heparin prophylaxis for thromboembolic disease), diagnosis (eg, intravenous contrast) and monitoring (eg, glucose monitoring). Cardiovascular drugs, anticoagulants and anti-infective agents were most commonly associated with medication errors.¹ Ensuring that medications are used appropriately is a complex process involving professionals from many disciplines. Errors can occur at any stage in the process—from prescribing the correct drug, properly ordering, processing and dispensing the drug, administering the right drug to the right patient, informing the patient about the medication, monitoring the patients response, and identifying adverse events.² Errors of omission were most common in both ICU and non ICU settings, whereas errors caused by improper dose or incorrect administration technique were more common in the ICU setting in a national study of voluntarily reported medication errors.⁵ In an observational study involving a surgical ICU in a tertiary care hospital, 87.5% of doses for weight-based infusions were calculated based on estimated or unreliable admission weights.⁶

The most common medical error reported in an observational prospective multicenter cohort study of 70 ICUs was related to insulin administration, 186 errors per 1,000 days of insulin treatment.³ During the time of this study, tight glucose control was advocated in ICUs.⁷ Subsequent studies examined the risk-benefit of tight glucose control and the practice remains controversial in ICUs today.⁸ Other medication errors included administering anticoagulant medication, prescribing anticoagulant medication, and administering vasoactive agents.³ A recent review of medication errors in the ICU found substantial differences in medication error rates, varying from 18.6 to 146.1 per 1000 patient care days. Studies that reported higher medication error rates included observation methods and did not rely on voluntary reporting alone suggesting an under reporting of error when self reporting is the only tracking method.⁹

While the use of computerized physician order entry (CPOE) has reduced errors in medication dose, route, substitution, and allergy and has intercepted adverse drug events, its use in the ICU can potentially increase the rates of certain medication errors, or result in entirely new error types. These include medication discontinuation failures, antibiotic renewal failures, unreliable reinstitution of medications following surgery and problems with nonformulary medications.¹⁰ Alert fatigue is another common problem created by computerized entry of orders as the number of cautionary alerts increases, so too does the provider ability to tune them out.

Many ICU patients will be mechanically ventilated at some point during the course of their critical illness. Mechanically ventilated patients can experience complications from the initiation of mechanical ventilation all the way through to their extubation. These complications include esophageal intubation, hemodynamic instability in the peri-intubation period from sedation, hypoxemia, or delay in intubation. Once patients are intubated, endotracheal tubes can become dislodged, clogged or inadvertently removed by the patient. The rate of self-extubation has been reported to occur in about 5% to 15% of intubated patients.

Mechanical ventilation and the positive pressure patients are exposed to can lead to barotrauma and further complications. Use of a video laryngoscope can significantly reduce the number of esophageal intubations and increase first pass success during intubation.¹¹ The adoption of a combined team approach to urgent endotracheal intubation with designated roles for team members, a mandatory checklist and back-up plan, can minimize peri-intubation complications.¹²

Critically ill patients often require central venous lines for access, monitoring and therapy (eg, dialysis, ECMO). Complications can occur from start to finish—wrong site, improper sterile technique, poor procedural technique, including poor knowledge of the anatomy, resulting in bleeding, local trauma including injury of vessels or underlying lung (eg, pneumothorax), and infectious complications. The presence of a central venous catheter and mechanical ventilation were among the factors independently associated with having at least one medical error in a recent study.³

The use of ultrasound to guide invasive procedures such as central line placement and thoracentesis has made them much safer as the anatomy can be directly visualized. A multidisciplinary approach employing a “time out” can make it difficult for errors of site or identification to occur.

Nasogastric tubes for enteral feeding and medication access can be dislodged or incorrectly positioned, entering the airway instead of the esophagus, resulting in trauma to the lung. Furthermore, patients must be positioned in a semi-recumbent position to minimize the chances of aspiration. Careful monitoring of positioning, securing of these tubes and appropriate sedation of the patient can avoid many complications.

Intern fatigue has been linked to serious medical errors in ICUs. One prospective, randomized study compared the rates of serious medical errors made by interns working a traditional schedule with an every third night call schedule versus an intervention schedule that eliminated extended work shifts and reduced the total number of hours worked per week. Interns made 35.9% more serious medical errors during the traditional schedule than during the intervention schedule. The total rate of serious errors was 22% higher during the traditional schedule.¹³ As a result of studies like these, the Accreditation Council for Graduate Medical Education (ACGME) restricted trainees to 16 consecutive hours of work. Shorter work shifts have resulted in a significant increase in the frequency of transitions of care (eg, handoffs) in the ICU. Improving the handoff process with the use of a structured note and face-to-face handoff can reduce medical error.

Truth telling in the setting of medical error or complication is generally the best approach. Interestingly a recent study showed that one fifth of physicians reported not fully disclosing medical error or mistakes to patients for fear of malpractice lawsuits.¹⁴ The first priority is always to promptly diagnose and treat the complication. Careful documentation in the medical record is a critical next step. Informing the patient, family or surrogate is often difficult but part of good medical care. When discussing the situation, it is helpful to describe the situation, how it happened and the course of action to be taken to resolve the problem whenever possible. Never lie about or cover up a mistake.

The ICU is a complex and dangerous place for our patients. Patients are critically ill, require many medications, invasive lines and procedures, and 24/7 multidisciplinary care. This chapter outlines the most frequently encountered complications in ICU patients. Many hospital complications are preventable with good communication, oversight and education. Borrowing from other industries including the airlines and restaurant chains, hospitals have adopted methods and safety checklists to improve the reliability of the health care environment.¹⁵ The use of medical response teams for a faster response to a critically ill patient, remote ICU monitoring for greater oversight (eg, tele-ICU), and the adoption of critical care bundles and protocols are some of the methods being used to improve the safety of our patients in ICUs. The critical question is when will effective quality health care measures be available to every patient every time.