05/05/2026
Clinical pearls
WHEN TREATMENT INADVERTENTLY CAUSES HARM: ICU
What makes treating critically ill patients even more complex is that, besides the severity of their illness, treatment modalities can themselves inadvertently bring harm. This is why we should never underestimate the scale of work required to care for even one patient there.
It also means teams tasked to work there can never switch off at any point during their shift or call.
Let's look at some ways in which standard interventions practiced globally, with the best of intentions, can also be a source of harm, friends.
1. Turning patients.
An important care bundle in the ICU involves periodically turning patients to clean them and minimize the risk of pressure ulcers from prolonged lying in one position. It improves blood flow. If allowed to develop, pressure ulcers are notoriously difficult to treat and are associated with poorer outcomes.
The harm: It is during turning that some avoidable accidents have occurred. For example, a breathing tube (ETT) may dislodge, impairing ventilation, and, if undetected, can worsen outcomes. Other things to look out for are IV lines that are at risk of snapping.
The lesson: Practice line and tube care every time you turn patients. Remember to assess for dislodgement (tube length, auscultation, monitors) soon after turning them.
2. Oversedation
For patients who are on mechanical ventilation, sedation helps reduce anxiety and restlessness. A patient who "fights the ventilator" is at risk of cardiovascular instability and even injury (pulling out tubes). Sedation helps calm them.
The harm: While sedation is important, care bundles also remind carers to observe sedation breaks, because excessive sedation can lead to critical illness-associated weakness, in which the patient's muscles become progressively weaker, making it harder to wean them off mechanical support. It is even worse when sedation is routinely combined with long-acting muscle relaxant use.
The lesson: Daily sedation breaks, use muscle relaxants sparingly.
3. Ventilator-associated Lung Injury
Patients who are unable to protect their airways for various reasons, or who are at risk of respiratory failure, will require mechanical ventilation to meet oxygen demands and remove carbon dioxide during their treatment.
The harm: Ventilator use is not without complications. Patients may suffer lung injury from overdistension (common in ARDS, where lungs become stiff), cardiovascular complications like hypotension from a buildup of intrathoracic pressure, ventilator-acquired pneumonia, and oxygen toxicity, to name a few.
The lesson: Tailor ventilator modes and settings to the patient's altered physiology and review regularly, weaning as early as is appropriate, and daily ventilator care bundles (VAP)
4. Prophylactic antibiotics
Patients who undergo invasive procedures such as post-major surgery (thoracotomy, craniotomy, post-splenectomy), or those who are extremely low on white blood cells (chemotherapy), or have traumatic injuries, may require antibiotics to reduce the risk of infections.
The harm: While the intended benefit may be to prevent infections (e.g., ventilator-associated or central line-associated), inappropriate antibiotic use is associated with serious complications, including multidrug-resistant infections, fungal overgrowth, and, in some cases, worsening kidney injury.
The lesson: antibiotic stewardship to ensure justified and appropriate use; cultures to inform selection; limit duration of prophylaxis; and use the narrowest effective spectrum rather than a broad spectrum for routine prophylaxis.
5. Overhydration
Fluids remain a crucial component of the resuscitation of critically ill patients. Hypovolaemia, sepsis, and septic shock require fluid replacement to restore adequate delivery of oxygen and nutrients to tissues.
The harm: Excessive fluid administration can lead to poor outcomes, including fluid overload, impaired lung function (pulmonary edema), and increased cardiac workload (heart strain).
The Lesson: Use a conservative fluid administration approach with predefined targets (urine output, CVP, MAP), monitor for early warning signs of overload which may require diuretics, switch to enteral fluids as soon as the patient is hemodynamically stable, review fluid balance charts (input/output) regularly and daily weighing (modern ICU beds have this provision. It might not be available in most Low resource settings).
Well, there are several more examples, friends. But this list touches on a few common treatment hurdles to watch out for. Remain alert so your noble intentions do not cause harm.
I hope it helps.
Bless
