Practice Of Critical Care Medicine Research Articles

Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review.

This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes. The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement. This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.

Research Hotspots and Trends of Deep Learning in Critical Care Medicine: A Bibliometric and Visualized Study.

Interest in the application of deep learning (DL) in critical care medicine (CCM) is growing rapidly. However, comprehensive bibliometric research that analyze and measure the global literature is still lacking. The present study aimed to systematically evaluate the research hotspots and trends of DL in CCM worldwide based on the output of publications, cooperative relationships of research, citations, and the co-occurrence of keywords. A total of 1708 articles in all were obtained from Web of Science. Bibliometric analysis was performed by Bibliometrix package in R software (4.2.2), Microsoft Excel 2019, VOSviewer (1.6.18), and CiteSpace (5.8.R3). The annual publications increased steeply in the past five years, accounting for 95.67% (1634/1708) of all the included literature. China and USA contributed to approximately 71.66% (1244/1708) of all publications. Seven of the top ten most productive organizations rank in the top 100 universities globally. Hot spots in research on the application of DL in CCM have focused on classifying disease phenotypes, predicting early signs of clinical deterioration, and forecasting disease progression, prognosis, and death. Convolutional neural networks, long and short-term memory networks, recurrent neural networks, transformer models, and attention mechanisms were all commonly used DL technologies. Hot spots in research on the application of DL in CCM have focused on classifying disease phenotypes, predicting early signs of clinical deterioration, and forecasting disease progression, prognosis, and death. Extensive collaborative research to improve the maturity and robustness of the model remains necessary to make DL-based model applications sufficiently compelling for conventional CCM practice.

Clinical Performance of Decision Support Systems in Anesthesia, Intensive Care, and Emergency Medicine: A Systematic Review and Meta-Analysis.

Medical technology is expanding at an alarming rate, with its integration into health care often reflected by the constant evolution of best practices. This rapid expansion of available treatment modalities, when coupled with progressively increasing amounts of consequential data for health care professionals to manage, creates an environment where complex and timely decision-making without the aid of technology is inconceivable. Decision support systems (DSSs) were, therefore, developed as a means of supporting the clinical duties of health care professionals through immediate point-of-care referencing. The integration of DSS can be especially useful in critical care medicine, where the combination of complex pathologies, the multitude of parameters, and the general state of patients require swift informed decision-making. The systematic review and meta-analysis were performed to evaluate DSS outcomes compared to the standard of care (SOC) in critical care medicine. This systematic review and subsequent meta-analysis were performed after the EQUATOR networks Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). We systematically explored PubMed, Ovid, Central, and Scopus for randomized controlled trials (RCTs) from January 2000 to December 2021. The primary outcome of this study was to evaluate whether DSS is more effective than SOC practice in critical care medicine within the following disciplines: anesthesia, emergency department (ED), and intensive care unit (ICU). A random-effects model was used to estimate the effect of DSS performance, with 95% confidence intervals (CIs) in both continuous and dichotomous results. Outcome-based, department-specific, and study-design subgroup analyses were performed. A total of 34 RCTs were included for analysis. In total, 68,102 participants received DSS intervention, while 111,515 received SOC. Analysis of the continuous (standardized mean difference [SMD], -0.66; 95% CI [-1.01 to -0.30]; P < .01) and binary outcomes (odds ratio [OR], 0.64; 95% CI, [0.44-0.91]; P < .01) was statistically significant and suggests that health interventions are marginally improved with DSS integration in comparison to SOC in critical care medicine. Subgroup analysis in anesthesia (SMD, -0.89; 95% CI, [-1.71 to -0.07]; P < .01) and ICU (SMD, -0.63; 95% CI [-1.14 to -0.12]; P < .01) were deemed statistically supportive of DSS in improving outcome, with evidence being indeterminate in the field of emergency medicine (SMD, -0.24; 95% CI, [-0.71 to 0.23]; P < .01). DSSs were associated with a beneficial impact in critical care medicine on a continuous and binary scale; however, the ED subgroup was found to be inconclusive. Additional RCTs are required to determine the effectiveness of DSS in critical care medicine.

Military Soft Skills Applicable to the ICU.

A systematic search was performed in PubMed. We selected all studies that addressed soft skills in medicine. Information present in published articles was analyzed by the authors and incorporated in the article if relevant to the practice of critical care medicine. Integrative review of 15 articles combined with the authors' clinical experience practicing military medicine in country and overseas while also practicing academic intensive care medicine. Soft skills used in the military have potential applications to modern intensive care medicine. Teaching soft skills in parallel with the technical aspects of intensive care medicine should be an integral part of critical care fellowships.

Redefining critical illness.

Research and practice in critical care medicine have long been defined by syndromes, which, despite being clinically recognizable entities, are, in fact, loose amalgams of heterogeneous states that may respond differently to therapy. Mounting translational evidence-supported by research on respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection-suggests that the current syndrome-based framework of critical illness should be reconsidered. Here we discuss recent findings from basic science and clinical research in critical care and explore how these might inform a new conceptual model of critical illness. De-emphasizing syndromes, we focus on the underlying biological changes that underpin critical illness states and that may be amenable to treatment. We hypothesize that such an approach will accelerate critical care research, leading to a richer understanding of the pathobiology of critical illness and of the key determinants of patient outcomes. This, in turn, will support the design of more effective clinical trials and inform a more precise and more effective practice at the bedside.

(Plenary) Electrochemical/Optical Sensors in Medicine: Meeting Needs for the 21st Century

Over the past 40 years, miniaturized potentiometric and amperometric sensors for ions (K+, Ca++, Na+, Mg++, Cl-, H+), gases (O2 and CO2), and nutrients/metabolites (glucose, lactate, creatinine, urea) have revolutionized the practice of critical care medicine by providing tools to measure an array of these physiologically important species, simultaneously, in small volumes of undiluted whole blood. Indeed, all modern point-of-care whole blood analyzers used in hospitals worldwide now employ electrochemical sensor arrays as either single-use or multi-use devices for near-patient testing, especially in operating rooms, emergency rooms, intensive care units, etc. Some of the same or similar chemistries have also been adapted to create either single-use or continuous monitoring optical sensors (fluorescence, etc.). Further, nearly all blood glucometers as well as newer implantable subcutaneous glucose sensors now use electrochemical measurement principles to provide accurate glucose concentrations for millions of diabetic patients each and every day. A brief overview of these existing electrochemical/optical sensor technologies that have already had such a great impact in medicine will be provided during the introductory portion of this lecture.At the same time, there remain a number of unmet needs in medicine where electrochemical/optical chemical sensing devices could still play important analytical roles. Therefore, in the major portion of this presentation, the following research projects ongoing in our laboratories at the University of Michigan will be highlighted: 1) recent efforts to utilize electrochemical sensors for measurement of polyionic drugs and associated contaminants (including the anticoagulant heparin, low-molecular weight heparin, and inflammatory over-sulfated chondroitin sulfate (OSCS) contaminants in biomedical heparin preparations);1-2 2) research aimed at utilizing the same chemistry employed to make ion and polyion selective electrochemical sensors to create optical sensing films as well as optical sensing microfluidic devices that are able to quantitate species in volumes of << 1 µL;3 3) research related to the development of implantable electrochemical sensors for ions, gases, glucose, lactate, etc. that emit low levels of nitric oxide (NO) (a potent anti-platelet and antimicrobial agent) and that can potentially be used to continuously monitor critical care species intravenously in ICU patients with improved accuracy (see Fig. 1);4 and 4) efforts to use improved electrochemical/amperometric gas phase sensors for detecting nitric oxide (NO) in exhaled nasal/oral breath and also the use of NO and nitrogen dioxide (NO2) sensors to monitor and feedback control the levels of therapeutic gas phase NO being generated by novel photochemical and electrochemical gas phase generators.5-6 These gas phase NO generators can potentially replace use of very high cost compressed gas cylinders containing NO to provide controlled levels of NO gas on-demand for inhalation therapy of patients with pulmonary hypertension (including infants) and for use in the sweep gas of oxygenators to prevent clotting and Systemic Inflammatory Response Syndrome (SIRS) in patients undergoing open heart surgery.Literature Cited: L. Wang, S. Buchanan and M. E. Meyerhoff, “Rapid Detection of High Charge Density Polyanion Contaminants in Biomedical Heparin Preparations Using Potentiometric Polyanion Sensors,” Anal. Chem., 80, 9845-9847 (2008).K. Gemene and M. E. Meyerhoff, “Reversible Detection of Heparin and Other Polyanions by Pulsed Chronopotentiometric Polymer Membrane Electrode,” Anal. Chem., 82, 1612-1615 (2010).X. Wang, M. Sun, S. A. Ferguson, J. D. Hoff, Y. Qin, R. C. Bailey, and M. E. Meyerhoff, “Ionophore-Based Biphasic Chemical Sensing in Droplet Microfluidics,” Angew. Chem. Int. Ed., 58, 1-6 (2019).M. Frost and M. E. Meyerhoff, “Real-Time Monitoring of Critical Care Analytes in the Bloodstream with Chemical Sensors: Progress and Challenges,” Ann. Rev. Anal. Chem., 8, 171-192 (2015).J. Zajda, N. J. Schmidt, Z. Zheng, X. Wang and M. E. Meyerhoff, “Evaluation of Amperometric Platinized-Nafion-Based Gas Phase Sensor for Determining Nitric Oxide (NO) Levels in Exhaled Human Nasal Breath,” Electroanalysis 30, 1602-1607 (2018).Y. Qin, J. Zajda, H. Ren, J. Toomasian, T. Major, A. Rojas-Pena, B. Carr, T. Johnson , J. Haft, R. H. Bartlett, A. Hunt, N. Lehnert, and M. E. Meyerhoff, “Low Cost Portable Gas Phase Nitric Oxide (NO) Generator Based on Electrochemical Reduction of Nitrite for Potential Applications in Inhaled NO Therapy and Within the Sweep Gas/Cardiotomy Suction Air During Cardiopulmonary Bypass Surgery,” Mol. Pharmaceutics, 14, 3762-3771 (2017). Figure 1. Comparison of average error of PO2 levels using amperometric IV-oxygen sensing catheters with (n=4) and without (n=4) NO release chemistry placed into the arteries of pigs for 20 h. % deviation calculated vs. measurements made on discrete whole blood samples (heparinized syringe) on Radiometer blood-gas/electrolyte analyzer. Figure 1

Standardization of critical care management of non-critically ill patients with COVID-19.

The large global outbreak of coronavirus disease 2019 (COVID-19) has seriously endangered the health care system in China and globally. The sudden surge of patients with severe acute respiratory syndrome coronavirus 2 infection has revealed the shortage of critical care medicine resources and intensivists. Currently, the management of non-critically ill patients with COVID-19 is performed mostly by non-intensive care unit (ICU) physicians, who lack the required professional knowledge, training, and practice in critical care medicine, especially in terms of continuous monitoring of the respiratory function, intervention, and feedback on treatment effects. This clinical problem needs an urgent solution. Therefore, here, we propose a series of clinical strategies for non-ICU physicians aimed at the standardization of the management of non-critically ill patients with COVID-19 from the perspective of critical care medicine. Isolation management is performed to facilitate the implementation of hierarchical monitoring and intervention to ensure the reasonable distribution of scarce critical care medical resources and intensivists, highlight the key patients, timely detection of disease progression, and early and appropriate intervention and organ function support, and thus improve the prognosis. Different management objectives are also set based on the high-risk factors and the severity of patients with COVID-19. The approaches suggested herein will facilitate the timely detection of disease progression, and thus ensure the provision of early and appropriate intervention and organ function support, which will eventually improve the prognosis.

Safety and Efficacy of Dexmedetomidine in Breast Surgeries: A Systematic Review and Meta-Analysis

PurposePain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries. DesignSystematic review and meta-analysis. MethodsThe present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019. FindingsTwelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery. ConclusionsThe results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV.

Focused Cardiac Ultrasound is Applicable to Internal Medicine and Critical Care but Skill Gaps Currently Limit Use.

ContextCoronavirus Disease 2019 (COVID-19) put a spotlight on focused cardiac ultrasound (FoCUS). However, the spectra of cardiac disease, and the resources available for investigation vary internationally. The applicability of FoCUS to internal medicine (IM) and critical care medicine (CCM) practice in Saudi Arabia and their current use of FoCUS are unknown.AimsTo determine the applicability of FoCUS to IM and CCM practice in Saudi Arabia and quantify the residents’ current proficiency, accreditation and use of FoCUS.MethodsA questionnaire was distributed to the residents in IM and CCM at our institution to determine their proficiency, use of FoCUS, and perceptions of its applicability.ResultsIn total, 110 residents (IM 100/108; CCM 10/10) participated (Response rate 93.2%) and reported that FoCUS was very applicable to their practice, most specifically for pericardial effusion, right heart strain, and left ventricular function. Two IM residents had received postgraduate training, ten used FoCUS regularly, none were accredited and overall self-reported proficiency was poor. In contrast all CCM residents had received postgraduate training and reported regular use of FoCUS. Two were accredited.ConclusionsWhilst FoCUS is applicable to IM practice in Saudi Arabia, significant skills gaps exist. The skills gap in CCM is lower but unaccredited practice is common. Our residents’ responses were similar to those from Canada. Thus, international standardization of FoCUS training could be considered.

Critical Care Medicine Practice: A Pilot Survey of US Anesthesia Critical Care Medicine-Trained Physicians.

This survey assessed satisfaction with the practice environment among physicians who have completed fellowship training in critical care medicine (CCM) as recognized by the American Board of Anesthesiology (and are members of the American Society of Anesthesiology) and evaluated the perceived effectiveness of training programs in preparing fellows for critical care practice. A cross-sectional online survey composed of 39 multiple choice and open-ended questions was administered between August and December 2018 to all members of the American Society of Anesthesiologists (ASA) who self-identified as being CCM trained. The survey instrument was developed and revised in an iterative fashion by ASA committee on CCM and the Society for Education in Anesthesia (SEA). Survey results were analyzed using a mixed-method approach. Three hundred fifty-three of the 1400 anesthesiologists who self-identified to the ASA as having CCM training (25.2%) completed the survey. Most were men (72.3%), board certified in CCM (98.7%), and had practiced a median of 5 years. Half of the respondents rated their training as "excellent." A total of 70.6% described currently working in academic centers with 53.6% providing care in open surgical intensive care units (ICUs). Most anesthesiologist intensivists (75%) spend at least 25% of their clinical time providing ICU care (versus clinical anesthesia). A total of 89% of the respondents were involved in educational activities, 60% reported being in administrative leadership roles, and 37% engaged in scholarly activity. Areas of dissatisfaction included fatigue, lack of collegiality or respect, lack of research training, decreased job satisfaction, and burnout. Analysis suggested moderate levels of job satisfaction (49%), work-life balance (52%), and high levels of burnout (74%). A significant contributor to burnout was with a perception of lack of respect (P = .005) in the work environment. Burnout was not significantly associated with gender or duration of practice. Qualitative analysis of the open-ended responses also identified these 3 variables as major themes. This survey of CCM-trained anesthesiologists described a high rate of board certification, practice in academic settings, and participation in resident education. Areas of dissatisfaction with an anesthesia/critical care practice included burnout, work/life balance, and lack of respect. These results may increase recruitment of anesthesiologists into critical care and inform strategies to improve satisfaction with anesthesia critical care practice, fellowship training.

(Plenary) Electrochemical/Optical Sensors in Medicine: Meeting Needs for the 21st Century

Over the past 40 years, miniaturized potentiometric and amperometric sensors for ions (K+, Ca++, Na+, Mg++, Cl-, H+), gases (O2 and CO2), and nutrients/metabolites (glucose, lactate, creatinine, urea) have revolutionized the practice of critical care medicine by providing tools to measure an array of these physiologically important species, simultaneously, in small volumes of undiluted whole blood. Indeed, all modern point-of-care whole blood analyzers used in hospitals worldwide now employ electrochemical sensor arrays as either single-use or multi-use devices for near-patient testing, especially in operating rooms, emergency rooms, intensive care units, etc. Some of the same or similar chemistries have also been adapted to create either single-use or continuous monitoring optical sensors (fluorescence, etc.). Further, nearly all blood glucometers as well as newer implantable subcutaneous glucose sensors now use electrochemical measurement principles to provide accurate glucose concentrations for millions of diabetic patients each and every day. A brief overview of these existing electrochemical/optical sensor technologies that have already had such a great impact in medicine will be provided during the introductory portion of this lecture.At the same time, there remain a number of unmet needs in medicine where electrochemical/optical chemical sensing devices could still play important analytical roles. Therefore, in the major portion of this presentation, the following research projects ongoing in our laboratories at the University of Michigan will be highlighted: 1) recent efforts to utilize electrochemical sensors for measurement of polyionic drugs and associated contaminants (including the anticoagulant heparin, low-molecular weight heparin, and inflammatory over-sulfated chondroitin sulfate (OSCS) contaminants in biomedical heparin preparations);1-2 2) research aimed at utilizing the same chemistry employed to make ion and polyion selective electrochemical sensors to create optical sensing films as well as optical sensing microfluidic devices that are able to quantitate species in volumes of << 1 µL;3 3) research related to the development of implantable electrochemical sensors for ions, gases, glucose, lactate, etc. that emit low levels of nitric oxide (NO) (a potent anti-platelet and antimicrobial agent) and that can potentially be used to continuously monitor critical care species intravenously in ICU patients with improved accuracy (see Fig. 1);4 and 4) efforts to use improved electrochemical/amperometric gas phase sensors for detecting nitric oxide (NO) in exhaled nasal/oral breath and also the use of NO and nitrogen dioxide (NO2) sensors to monitor and feedback control the levels of therapeutic gas phase NO being generated by novel photochemical and electrochemical gas phase generators.5-6 These gas phase NO generators can potentially replace use of very high cost compressed gas cylinders containing NO to provide controlled levels of NO gas on-demand for inhalation therapy of patients with pulmonary hypertension (including infants) and for use in the sweep gas of oxygenators to prevent clotting and Systemic Inflammatory Response Syndrome (SIRS) in patients undergoing open heart surgery.Literature Cited: 1. L. Wang, S. Buchanan and M. E. Meyerhoff, “Rapid Detection of High Charge Density Polyanion Contaminants in Biomedical Heparin Preparations Using Potentiometric Polyanion Sensors,” Anal. Chem., 80, 9845-9847 (2008).2. K. Gemene and M. E. Meyerhoff, “Reversible Detection of Heparin and Other Polyanions by Pulsed Chronopotentiometric Polymer Membrane Electrode,” Anal. Chem., 82, 1612-1615 (2010).3. X. Wang, M. Sun, S. A. Ferguson, J. D. Hoff, Y. Qin, R. C. Bailey, and M. E. Meyerhoff, “Ionophore-Based Biphasic Chemical Sensing in Droplet Microfluidics,” Angew. Chem. Int. Ed., 58, 1-6 (2019).4. M. Frost and M. E. Meyerhoff, “Real-Time Monitoring of Critical Care Analytes in the Bloodstream with Chemical Sensors: Progress and Challenges,” Ann. Rev. Anal. Chem., 8, 171-192 (2015).5. J. Zajda, N. J. Schmidt, Z. Zheng, X. Wang and M. E. Meyerhoff, “Evaluation of Amperometric Platinized-Nafion-Based Gas Phase Sensor for Determining Nitric Oxide (NO) Levels in Exhaled Human Nasal Breath,” Electroanalysis 30, 1602-1607 (2018).6. Y. Qin, J. Zajda, H. Ren, J. Toomasian, T. Major, A. Rojas-Pena, B. Carr, T. Johnson , J. Haft, R. H. Bartlett, A. Hunt, N. Lehnert, and M. E. Meyerhoff, “Low Cost Portable Gas Phase Nitric Oxide (NO) Generator Based on Electrochemical Reduction of Nitrite for Potential Applications in Inhaled NO Therapy and Within the Sweep Gas/Cardiotomy Suction Air During Cardiopulmonary Bypass Surgery,” Mol. Pharmaceutics, 14, 3762-3771 (2017). Figure 1

Establishing the Knowledge and Skills Necessary in Pediatric Critical Care Medicine: A Systematic Approach to Practice Analysis.

To describe the practice analysis undertaken by a task force convened by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to create a comprehensive document to guide learning and assessment within Pediatric Critical Care Medicine. An in-depth practice analysis with a mixed-methods design involving a descriptive review of practice, a modified Delphi process, and a survey. Not applicable. Seventy-five Pediatric Critical Care Medicine program directors and 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates. A practice analysis document, which identifies the full breadth of knowledge and skill required for the practice of Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatrics Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine content outline, which was sent to all 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates for review during an open-comment period between January 2019 and February 2019, and diplomate feedback was used to make updates to both the content outline and the practice analysis document. After review and comment by 25 Pediatric Critical Care Medicine program directors (33.3%) and 619 board-certified diplomates (24.4%), a comprehensive practice analysis document was created through a two-stage process. The final practice analysis includes 10 performance domains which parallel previously published Entrustable Professional Activities in Pediatric Critical Care Medicine. These performance domains are made up of between three and eight specific tasks, with each task including the critical knowledge and skills that are necessary for successful completion. The final practice analysis document was also used by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to update the Pediatric Critical Care Medicine content outline. A systematic approach to practice analysis, with stakeholder engagement, is essential for an accurate definition of Pediatric Critical Care Medicine practice in its totality. This collaborative process resulted in a dynamic document useful in guiding curriculum development for training programs, maintenance of certification, and lifetime professional development to enable safe and efficient patient care.

Anaesthesiologist-intensivist phycisians at the core of the management of critically ill COVID-19 patients in Africa: persistent challenges, some resolved dilemma and future perspective.

Unlike developed countries which have purely intensivists also called critical care physicians or intensive care physicians to manage critically ill patients like those with severe forms of COVID-19, the practice of critical care medicine in Africa is coined to anaesthesiology. Hence, anaesthesiologist-intensivist physicians are the medical specialists taking care of critically ill COVID-19 patients in Africa. Likewise, unlike intensive care units (ICUs) in high income countries, those in most African countries face the challenge of a lack of emergency drugs and resuscitation equipment, limited health infrastructure and understaffed and underfunded health care systems. The COVID-19 pandemic is an unprecedented one faced by intensivists in high-income countries and anaesthesiologist-intensivist phycisians in Africa. Infected patients with severe forms of the disease like those having grave COVID-19 complications like massive pulmonary embolism, severe cardiac arrhythmias, cardiogenic shock, septic shock, acute kidney injury or acute respiratory distress syndrome require ICU admission for better management. Both intensivists or anaesthesiologist-intensivist physicians have the peculiarity of securing the airways of critically COVID-19 patients and providing respiratory support with mechanical ventilation after laryngoscopy and endotracheal intubation when needed. In so doing, they can easily be infected from respiratory droplets or aerosols expired by the COVID-19 patients. Hence, in Africa, anaesthesiologist-intensivist phycisians have a higher risk of contracting COVID-19 compared to other health professionals. It's worth to mention that the COVID-19 pandemic struck African anaesthesiologist-intensivist phycisians and ICUs when there were neither prepared skillfully or lacked the required ICU capacity to meet the demands of thousands of severe COVID-19 African patients. These further weakened the already strained health systems in Africa. It required a lot of creativity, engineering skills and courage for these ill prepared African anaesthesiologist-intensivist physicians to provide care to these critically ill patients and improve their outcomes as the pandemic progressed. However, despites the numerous efforts made in African anaesthesiologist-Intensivist phycisians to care for critically ill COVID-19 patients, the pandemic is spreading at a rapid rate across Africa. There is an urgent need for African health authorities to anticipate on how to scale up the future high ICU capacity needs and limited ICU workforce, infrastructure and equipment to manage severe forms of COVID-19 in future. It cannot be overemphasized that these severe forms of COVID-19 are potentially fatal and are a major contributor to the death toll of the COVID-19 pandemic.

Anaesthesiologist-intensivist phycisians at the core of the management of critically ill COVID-19 patients in Africa: persistent challenges, some resolved dilemma and future perspective

Unlike developed countries which have purely intensivists also called critical care physicians or intensive care physicians to manage critically ill patients like those with severe forms of COVID-19, the practice of critical care medicine in Africa is coined to anaesthesiology. Hence, anaesthesiologist-intensivist physicians are the medical specialists taking care of critically ill COVID-19 patients in Africa. Likewise, unlike intensive care units (ICUs) in high income countries, those in most African countries face the challenge of a lack of emergency drugs and resuscitation equipment, limited health infrastructure and understaffed and underfunded health care systems. The COVID-19 pandemic is an unprecedented one faced by intensivists in high-income countries and anaesthesiologist-intensivist phycisians in Africa. Infected patients with severe forms of the disease like those having grave COVID-19 complications like massive pulmonary embolism, severe cardiac arrhythmias, cardiogenic shock, septic shock, acute kidney injury or acute respiratory distress syndrome require ICU admission for better management. Both intensivists or anaesthesiologist-intensivist physicians have the peculiarity of securing the airways of critically COVID-19 patients and providing respiratory support with mechanical ventilation after laryngoscopy and endotracheal intubation when needed. In so doing, they can easily be infected from respiratory droplets or aerosols expired by the COVID-19 patients. Hence, in Africa, anaesthesiologist-intensivist phycisians have a higher risk of contracting COVID-19 compared to other health professionals. It's worth to mention that the COVID-19 pandemic struck African anaesthesiologist-intensivist phycisians and ICUs when there were neither prepared skillfully or lacked the required ICU capacity to meet the demands of thousands of severe COVID-19 African patients. These further weakened the already strained health systems in Africa. It required a lot of creativity, engineering skills and courage for these ill prepared African anaesthesiologist-intensivist physicians to provide care to these critically ill patients and improve their outcomes as the pandemic progressed. However, despites the numerous efforts made in African anaesthesiologist-Intensivist phycisians to care for critically ill COVID-19 patients, the pandemic is spreading at a rapid rate across Africa. There is an urgent need for African health authorities to anticipate on how to scale up the future high ICU capacity needs and limited ICU workforce, infrastructure and equipment to manage severe forms of COVID-19 in future. It cannot be overemphasized that these severe forms of COVID-19 are potentially fatal and are a major contributor to the death toll of the COVID-19 pandemic.

Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome.

Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014. To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery. We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS. We used standard methodological procedures expected by Cochrane. We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants). Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS.Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.

Monitoring intensive care unit performance—impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol

IntroductionPatients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance...

Critical Care and Personalized or Precision Medicine: Who needs whom?

The current paradigm of modern healthcare is a reactive response to patient symptoms, subsequent diagnosis and corresponding treatment of the specific disease(s). This approach is predicated on methodologies first espoused by the Cnidean School of Medicine approximately 2500years ago. More recently escalating healthcare costs and relatively poor disease treatment outcomes have fermented a rethink in how we carry out medical practices. This has led to the emergence of “P-Medicine” in the form of Personalized and Precision Medicine. The terms are used interchangeably, but in fact there are significant differences in the way they are implemented. The former relies on an “N-of-1” model whereas the latter uses a “1-in-N” model. Personalized Medicine is still in a fledgling and evolutionary phase and there has been much debate over its current status and future prospects. A confounding factor has been the sudden development of Precision Medicine, which has currently captured the imagination of policymakers responsible for modern healthcare systems. There is some confusion over the terms Personalized versus Precision Medicine. Here we attempt to define the key differences and working definitions of each P-Medicine approach, as well as a taxonomic relationship tree. Finally, we discuss the impact of Personalized and Precision Medicine on the practice of Critical Care Medicine (CCM). Practitioners of CCM have been participating in Personalized Medicine unknowingly as it takes the protocols of sepsis, mechanical ventilation, and daily awakening trials and applies it to each individual patient. However, the immediate next step for CCM should be an active development of Precision Medicine. This developmental process should break down the silos of modern medicine and create a multidisciplinary approach between clinicians and basic/translational scientists.

Why do we fail to deliver evidence-based practice in critical care medicine?

The use of evidence-based practices in clinical practice is frequently inadequate. Recent research has uncovered many barriers to the implementation of evidence-based practices in critical care medicine. Using a comprehensive conceptual framework, this review identifies and classifies the barriers to implementation of several major critical care evidence-based practices. The many barriers that have been recently identified can be classified into domains of the consolidated framework for implementation research (CFIR). Barriers to the management of patients with acute respiratory distress syndrome (ARDS) include ARDS under-recognition. Barriers to the use of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle for mechanically ventilated patients and the sepsis bundle include patient-related, clinician-related, protocol-related, contextual-related, and intervention-related factors. Although these many barriers can be classified into all five CFIR domains (intervention, outer setting, inner setting, individuals, and process), most barriers fall within the individuals and inner setting domains. There are many barriers to the implementation of evidence-based practice in critical care medicine. Systematically classifying these barriers allows implementation researchers and clinicians to design targeted implementation strategies, giving them the greatest chance of success in improving the use of evidence-based practice.

Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues.

Many patients are admitted to the ICU at or near the end of their lives. Consequently, the increasingly common debate regarding physician-assisted suicide and euthanasia holds implications for the practice of critical care medicine. The objective of this article is to explore core ethical issues related to physician-assisted suicide and euthanasia from the perspective of healthcare professionals and ethicists on both sides of the debate. We identified four issues highlighting the key areas of ethical tension central to evaluating physician-assisted suicide and euthanasia in medical practice: 1) the benefit or harm of death itself, 2) the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support, 3) the morality of a physician deliberately causing death, and 4) the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting. We present areas of common ground and important unresolved differences. We reached differing positions on the first three core ethical questions and achieved unanimity on how critical care clinicians should manage conscientious objections related to physician-assisted suicide and euthanasia. The alternative positions presented in this article may serve to promote open and informed dialogue within the critical care community.

Dexmedetomidine-induced neuroprotection: is it translational?

Dexmedetomidine is often used in anesthesia and critical care medicine practice to sedate patients. Its neuroprotective effects have been shown in various ischemic and hemorrhagic brain injury models of animals. Randomized clinical trials have indicated that dexmedetomidine can improve outcome of patients under intensive care. Clinical trials are needed to determine whether dexmedetomidine can provide neuroprotection against ischemic and hemorrhagic stroke.