Airway assessment, intubation and management of patients under mechanical ventilation is a common task in the intensive care unit. Invasive mechanical ventilation remains associated with the risks of airway and pulmonary complications that can be life-threatening. Postoperative pulmonary complications (PPC) are also common and serious, but optimal perioperative management can mitigate some of the risks of developing them. 

As Europeans continue to enjoy increasing lifespans, surgical and perioperative care for the elderly (> 65) and very old (> 85 years) has become commonplace, and will continue to increase in volume and complexity. This increase is due both to a larger proportion of the population reaching a high age, and to expansion of surgical care to individuals who were previously denied surgery because of risk vs benefit considerations. These are now being challenged. In the US, it is expected that the proportion of people aged 65 years and older will grow from 13% to > 20% of the total population by 2030. Within the European Union, the proportion of people aged 80 years or more is projected to more than double, from 5.3 % in 2015 to 12.3 % in 2080.

Every year, over 200 million people worldwide undergo surgical procedures in the operating room (OR), and demand for surgery and anaesthesia is steadily increasing (Rose, J., et al. 2015; Weiser, T.G., et al. 2008; Uribe-Leitz, T., et al. 2015). In addition, many procedures - currently about 15 % of anaesthetic volume - are performed outside of the OR, e.g. in the radiology or endoscopy suite (Van De Velde, M., et al. 2009). Not only are the absolute numbers of patients on the rise, but, due to demographic change in high-income countries, more and more chronically ill patients will be candidates for surgical and non-surgical interventions. All these patients, many of them high-risk, need pre-interventional consultation and subsequently anaesthesia, post-anaesthesia, intermediate and intensive care.

Surgical treatments are offered to more patients than ever before with an estimated 300 million surgical procedures conducted worldwide every year. Yet, surprisingly little is known about perioperative outcomes. Patients undergoing surgery are now older and have more comorbidities than 20 years ago. A reasonable expectation from surgery is one of cure from the underlying disease, but failing this, long-term survival with minimal disability is desirable. Available studies usually focus on procedure-specific and short-term outcomes, with ‘hard’ end points such as mortality. Patient-reported outcomes are usually not reported and the effects of complications are under-investigated.

In this module we will address the long-term consequences of surgery, consider which long-term measures that may be appropriate to measure and examine how they may be implemented in real-life. Although each subsection may be studied individually and independently of the other subsections, we recommend that the module be studied in whole.

Communication is essential to human interaction and development. Communication is a key skill that is explored, practiced and examined in medical schools across the world. It constitutes a core competency of how we are assessed in our continuing medical careers. It is well recognised that poor communication is often the root cause of many complaints and critical incidents, which lead to patient harm, increased length of stay and poor staff morale.
Key to good communication is enabling a patient to be at the centre of decision-making about their treatment. All efforts must be taken to facilitate patients’ making fully informed decisions about immediate and on-going care needs and this may involve an assessment of capacity where necessary. If required extra support for patients must be provided to assist them in making an independent decision, but occasionally this is not possible and a decision must be made in the best interests of the individual concerned.

There is an increasing availability of decision aids, which can be utilised to make it easier for patients and clinicians to reach a shared-decision about the most appropriate way to progress their care and use of these tools should be encouraged. The validity of consent can be questioned in the event of a patient complaint.

It is inevitable that not all episodes of communication will be straightforward and conflict is something that all professionals will encounter at some point in their career. It is therefore essential that strategies to recognise, acknowledge and resolve conflict are part of the communication skill set.

Patients require admission to the intensive care unit (ICU) for treatment of a specific underlying pathology. Unfortunately, the burden of critical illness has many associated sequalae. Pain, agitation and delirium are such problems frequently encountered in the ICU. 

Pain can result from not only the underlying pathology, but also from surgical procedures and invasive interventions required to manage it. During this module we will explore pain in the ICU, highlighting the reasons patients experience it, the detrimental consequences of pain, how we can assess it and how we can manage it. 

Agitation is common in the ICU. This module will examine the reasons why it occurs and the measures we can take to address it. We will look in detail at the use of sedative medications in intensive care, the different drugs used, their indications and their risks. We will also explore how best to assess agitation and adjust sedatives in order to maximise their benefits while reducing their harm. 

Delirium is not only common in the intensive care population, it can also be considered a marker of disease severity and is associated with an increased risk of death. This module will examine the pathophysiology underlying delirium, its risk factors, how we can detect and measure delirium as well as how we can prevent it and potentially treat it. 

By the end of this module we hope you will have a greater understanding of these common problems encountered in critical care. Ultimately, we hope that this module provides a framework from which you should develop a tailored, person-centred and holistic approach to managing pain, agitation and delirium in your patients.