Choosing Wisely in intensive care medicine

A medicina intensiva caracteriza-se por ser uma especialidade na qual os resultados estão muito relacionados à capacidade de organização e trabalho em equipe. Por outro lado, o avanço tecnológico oferece grande variedade de exames e uma miríade de diferentes possibilidades de tratamentos e de procedimentos para a abordagem do paciente crítico. Porém, inúmeras vezes esse grande arsenal de possibilidades é utilizado de modo indevido, o que além de não proporcionar benefícios significativos para os pacientes, pode ocasionar riscos e danos desnecessários. Com base nesses princípios, a American Board of Internal Medicine Foundation (ABIM) iniciou uma campanha, em 2012, para identificar situações clínicas que deveriam ser questionadas quanto à sua indicação e utilização, com o objetivo de conscientizar os médicos sobre a importância de utilizar apenas as intervenções e os procedimentos indicados para os pacientes, e que não os colocasse em risco. Para isso, foram desenvolvidas listas com itens considerados mais relevantes para proporcionar tomadas de decisões conscientes, a qual foi denominada Choosing Wisely.(1) Desde então, inúmeras sociedades médicas ao redor do mundo passaram a realizar suas próprias listas, buscando fomentar a discussão e alertar sobre as principais condutas a serem questionadas e utilizadas sempre com o máximo de discernimento. São considerados princípios básicos da campanha: que seja liderada por médicos, as escolhas devem ser centradas no paciente, deve haver participação multiprofissional, ser baseada em evidências, e o processo de escolha precisa ser transparente.(2) A Associação de Medicina Intensiva Brasileira (AMIB) nomeou um grupo de experts para a elaboração das recomendações. Inicialmente, os especialistas elaboraram 28 recomendações e, pelo Método Delphi modificado, foram eliminadas aquelas que atingiam mais de 80% de consenso dentre eles. Ao final, chegaram às dez recomendações, que foram submetidas à escolha dos associados por meio de votação eletrônica, pelo site da associação (https://amorintensopelavida.com.br/choosing/). Os associados receberam, por e-mail, o convite para votar e foram identificados pelo CPF no momento do voto, para evitar duplicidade. Participaram 1.754 associados de todas as regiões do país, representando cerca de 30% dos associados AMIB. Todas as cinco recomendações mais votadas foram escolhidas por mais de 50% dos participantes, conforme figura 1.


-Do not use or maintain unnecessary antibiotics
The use of antibiotics should be restricted to patients with infection, always follow the clinical criteria, be used for the shortest time possible, and according to the best evidence. Broad-spectrum antimicrobial agents should be deescalated or discontinued once cultures are available. Approximately 10 years ago, Boucher et al. (3) called attention to the impact of the use of unnecessary antibiotics on the emergence of multiresistant bacteria, which became known as ESKAPE, an acronym for Enterococcus faecium, Staphylococus aureus, Klebsiella had an important impact on the recovery and functional capacity of patients at the time of hospital discharge. (7)

-Do not use or maintain invasive devices unnecessarily
The insertion and maintenance of invasive devices should always occur in a restrictive manner according to precise criteria. Routine surveillance is indicated to avoid as much as possible the insertion and prolonged use of tracheal and enteral tubes, as well as catheters and drains. There is evidence that the use of invasive devices is associated with infections and that their duration of use is prolonged either for the convenience of the professional team or because of a lack of protocols for their removal. (8,9) Pronovost and colleagues conducted a study in ICUs in the state of Michigan, in which they evaluated daily whether any catheters or tubes that were no longer necessary could be removed showing a significant decrease in bloodstream infections. (10)

-Do not offer Advanced Life Support in the end-oflife for patients that are likely to die
The establishment or maintenance of advanced support for critically ill patients with a high probability of death or significant sequela should be avoided unless the possibility of establishing palliative care is considered. Clinical decisions within this context should always be made while respecting the expressed will of patients or their family members after extensive dialogue and consensus. A recent study undertook by the World Federation of Societies of Intensive and Critical Care Medicine demonstrated wide variability in end-of-life practices in ICUs and the need of systematization. (10) Quality improvement, cost reduction, value maximization and better care for chronic critically ill patients are current challenges of our specialty. To this end, wiser choices can certainly contribute in a significant manner. Publicize the list, make it part of your daily routine, include it in the checklists used in your unit, and discuss these choices during multi-professional visits. Doing so we will advance a national dialogue on avoiding unnecessary treatments and procedures I order to achieve better outcomes as a result.

THE GROUP THAT ORGANIZED THE CHOOSING WISELY RECOMMENDATIONS OF AMIB:
Ederlon Alves de Carvalho Rezende, Mirella Cristine de Oliveira, Cristiano Augusto Franke, Marcos Knibel, Nelson Akamine, Álvaro Rea-Neto. pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa and Enterobacter species. Studies such as EPIC II (Extended Prevalence of Infection in Intensive Care) have shown that the number of patients admitted with an infection diagnosis to intensive care units (ICUs) in Latin America is higher than that in other regions of the world and that these patients have higher mortality. (4)

-Do not use excessive sedation
Limiting the use of sedation to patients with appropriate indications, using as few sedatives as necessary to maintain patient comfort, and using scales to systematically evaluate the titration of the drugs being used show improved clinical outcomes. (5) Among the numerous pieces of evidence, we highlight the ABC trial, which combined daily sedation interruption with the performance of spontaneous breathing tests and compared this strategy to the standard treatment strategy; the former showed improvement on all outcomes, including more time free from mechanical ventilation, shorter stays in the ICU and in the hospital, and above all, lower mortality at a 1-year follow-up. (6)

-Do not keep patients immobilized in bed without a clear indication
The immobilization of critically ill patients is associated with a higher incidence of complications and longer hospital stays. There is evidence that early mobilization accelerates recovery from critical illness and improves the quality of life during hospitalization and after discharge. Accordingly, the study by Schweickert showed that daily discontinuation of sedation combined with physical and occupational therapy