History of technology in the intensive care unit

The Evolution and Future of Intensive Care Management in the Era of Telecritical Care and Artificial Intelligence

Critical care practice has been embodied in the healthcare system since the institutionalization of intensive care units (ICUs) in the late '50s. Over time, this sector has experienced many changes and improvements in providing immediate and dedicated healthcare as patients requiring intensive care are often frail and critically ill with high mortality and morbidity rates. These changes were aided by innovations in diagnostic, therapeutic, and monitoring technologies, as well as the implementation of evidence-based guidelines and organizational structures within the ICU. In this review, we examine these changes in intensive care management over the past 40 years and their impact on the quality of care available to patients. Moreover, the current state of intensive care management is characterized by a multidisciplinary approach and the use of innovative technologies and research databases. Advancements such as telecritical care and artificial intelligence are being increasingly explored, especially since the COVID-19 pandemic, to reduce the length of hospitalization and ICU mortality. With these advancements in intensive care and ever-changing patient needs, critical care experts, hospital managers, and policymakers must also explore appropriate organizational structures and future enhancements within the ICU.

Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment

Background

Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).

Objective

The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.

Methods

The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).

Results

There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.

Conclusions

It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.

Dynamic Monitoring of Systemic Biomarkers with Gastric Sensors

Continuous monitoring in the intensive care setting has transformed the capacity to rapidly respond with interventions for patients in extremis. Noninvasive monitoring has generally been limited to transdermal or intravascular systems coupled to transducers including oxygen saturation or pressure. Here it is hypothesized that gastric fluid (GF) and gases, accessible through nasogastric (NG) tubes, commonly found in intensive care settings, can provide continuous access to a broad range of biomarkers. A broad characterization of biomarkers in swine GF coupled to time-matched serum is conducted . The relationship and kinetics of GF-derived analyte level dynamics is established by correlating these to serum levels in an acute renal failure and an inducible stress model performed in swine. The ability to monitor ketone levels and an inhaled anaesthetic agent (isoflurane) in vivo is demonstrated with novel NG-compatible sensor systems in swine. Gastric access remains a main stay in the care of the critically ill patient, and here the potential is established to harness this establishes route for analyte evaluation for clinical management.

Pediatric brain death certification: a narrative review

In the five decades since its inception, brain death has become an accepted medical and legal concept throughout most of the world. There was initial reluctance to apply brain death criteria to children as they are believed more likely to regain neurologic function following injury. In spite of early trepidation, criteria for pediatric brain death certification were first proposed in 1987 by a multidisciplinary committee comprised of experts in the medical and legal communities. Protocols have since been developed to standardize brain death determination, but there remains substantial variability in practice throughout the world. In addition, brain death remains a topic of considerable ethical, philosophical, and legal controversy, and is often misrepresented in the media. In the present article, we discuss the history of brain death and the guidelines for its determination. We provide an overview of past and present challenges to its concept and diagnosis from biophilosophical, ethical and legal perspectives, and highlight differences between adult and pediatric brain death determination. We conclude by anticipating future directions for brain death as related to the emergence of new technologies. It is our position that providers should endorse the criteria for brain death diagnosis in children as proposed by the Society of Critical Care Medicine (SCCM), American Academy of Pediatrics (AAP), and Child Neurology Society (CNS), in order to prevent controversy and subjectivity surrounding what constitutes life versus death.

Brain death and management of the potential donor

One of the first attempts to define brain death (BD) dates from 1963, and since then, the diagnosis criteria of that entity have evolved. In spite of the publication of practice parameters and evidence-based guidelines, BD is still causing concern and controversies in the society. The difficulties in determining brain death and making it understood by family members not only endorse futile therapies and increase health care costs, but also hinder the organ transplantation process. This review aims to give an overview about the definition of BD, causes, physiopathology, diagnosis criteria, and management of the potential brain-dead donor. It is important to note that the BD determination criteria detailed here follow the AAN’s recommendations, but the standard practice for BD diagnosis varies from one country to another.

[Interaction between humans and non-humans in a pediatric intensive care unit]

Technology is a central element for patients in intensive care. The article aimed to explore the interpretations of interactions between humans and non-humans in the production of care for children with complex chronic conditions in the intensive care unit (ICU). Secondarily, the study discussed the secret as one of the dimensions of interactions associated with the intensive care setting. This was an ethnographic study with participant observation and field diary records, in dialogue with Actor-Network Theory, to discuss the role of technology in social interactions in the context of complex care in a pediatric ICU. Children, families, and professionals attributed new meanings and functionalities to the technology during prolonged stay in the ICU, redefining its role and assuming it as an important mediator in the social interactions between life inside and outside the hospital. Technological incorporation reconfigured the limits of life and the physical and symbolic spaces involving the care and stretched the limits between the public and private spheres during hospitalization. The secret in this setting was traversed by the technological mediation that added new ingredients to the relations of sociability. This new order, linked to interaction between humans and non-humans, challenges health institutions and their staff to rethink their values, procedures, and way of interacting in order to improve the patient's care, where technological incorporation is a definitive and innovative reality in what could be called the digitization of life and care.

Ethical Issues in Organ Transplantation at End of Life: Defining Death

End-of-life vital organ transplantation involves singular ethical issues, because survival of the donor is impossible, and organ retrieval is ideally as close to the death of the donor as possible to minimize organ ischemic time. Historical efforts to define death have been met with confusion and discord. Fifty years on, the Harvard criteria for brain death continue to be problematic and now face significant legislative efforts to limit their authority.

The Fundamentals of Critical Care Support: local experience and a look into the future

Fundamentals of Critical Care Support (FCCS) is an educational course offered by the Society of Critical Care Medicine (USA) to provide and augment the basic knowledge for individuals managing critically ill patients. More than 10,000 clinicians every year throughout the world attend FCCS courses, preparing non‐intensivists to manage critically ill patients for the first 24 h until a consultation can be secured. The most important emphasis of the FCCS course is to learn the basic principles and the adaptation of multidisciplinary approaches to managing the critically ill. The curriculum consists of integrated lectures and skills stations helping to provide the knowledge and guidance in decision making. This article is an account of one institution's experience in offering this course for over 12 years.

Medically Timed Death as an Enactment of Good Death: An Ethnographic Study of Three European Intensive Care Units

The article is based on ethnographic observation and semistructured interviews with personnel in three European adult intensive care units. Intensive care is a domain of contemporary biomedicine centered on invasive and intense efforts to save lives in acute, critical conditions. It echoes our culture's values of longevity. Nevertheless, mortality rates are elevated. Many deaths follow from nontreatment decisions. Medicalized dying in technological medical settings are often presented as unnatural, impersonal, and undesirable ways of dying. How does this affect the way in which death is experienced by intensive care professionals? What might the enactment of dying in intensive care reveal about our cultural values of good and bad dying?

The evolution of Australian intensive care and its related costs: A narrative review

OBJECTIVE

To conduct a narrative review on the evolution of intensive care and the cost of intensive care services in Australia.

REVIEW METHOD

A narrative review using a search of online medical databases and grey literature with keyword verification via Delphi-technique.

DATA SOURCES

Using Medical Subject Headings and keywords (intensive care, critical care, mechanical ventilation, renal replacement therapy, extracorporeal membrane oxygenation, monitoring, staffing, cost, cost analysis) we searched MEDLINE, PubMed, CINAHL, Embase, Google and Google Scholar.

RESULTS

The search yielded 30 articles from which we provide a narrative synthesis on the evolving intensive care practice in relation to key service elements and therapies. For the review of costs, we found five relevant publications and noted significant variation in methods used to cost ICU. Notwithstanding the limitations of the methods used to cost all publications reported staffing as the primary cost driver, representing up to 71% of costs.

CONCLUSION

Intensive care is a highly specialised medical field, which has developed rapidly and plays an increasingly important role in the provision of hospital care. Despite the increasing importance of the specialty and the known resource intensity there is a paucity of data on the cost of providing this service. In Australia, staffing costs consistently represent the majority of costs associated with operating an ICU. This finding should be interpreted cautiously given the variation of methods used to cost ICU services and the limited number of available studies. Developing standardised methods to consistently estimate ICU costs which can be incorporated in research into the cost-effectiveness of alternate practice is an important step to ensuring cost-effective care.

Botulism mortality in the USA, 1975-2009

Botulism had mortality rates >60% before the 1950s. We reviewed confirmed botulism cases in the USA during 1975-2009 including infant, foodborne, wound, and other/unknown acquisition categories, and calculated mortality ratios. We created a multivariate logistic regression model for non-infant cases (foodborne, wound, and other/unknown). Overall mortality was 3.0% with 109 botulism-related deaths among 3,618 botulism cases [18 (<1%) deaths among 2,352 infant botulism cases, 61 (7.1%) deaths among 854 foodborne botulism cases, 18 (5.0%) deaths among 359 wound botulism cases, and 12 (22.6%) deaths among 53 other/unknown botulism cases]. Mortality among all cases increased with age; it was lowest among infants (0.8%) and highest among persons ≥80 years old (34.4%). Toxin type F had higher mortality (13.8%) than types A, B, or E (range, 1.4% to 4.1%). Efforts to reduce botulism mortality should target non-infant transmission categories and older adults.

Skin antisepsis for reducing central venous catheter-related infections

BACKGROUND

The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs.

OBJECTIVES

To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities.

SEARCH METHODS

In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs).

MAIN RESULTS

Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events.

AUTHORS' CONCLUSIONS

It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.

East-West differences in perception of brain death. Review of history, current understandings, and directions for future research

The concept of brain death as equivalent to cardiopulmonary death was initially conceived following developments in neuroscience, critical care, and transplant technology. It is now a routine part of medicine in Western countries, including the United States. In contrast, Eastern countries have been reluctant to incorporate brain death into legislation and medical practice. Several countries, most notably China, still lack laws recognizing brain death and national medical standards for making the diagnosis. The perception is that Asians are less likely to approve of brain death or organ transplant from brain dead donors. Cultural and religious traditions have been referenced to explain this apparent difference. In the West, the status of the brain as home to the soul in Enlightenment philosophy, combined with pragmatism and utilitarianism, supports the concept of brain death. In the East, the integration of body with spirit and nature in Buddhist and folk beliefs, along with the Confucian social structure that builds upon interpersonal relationships, argues against brain death. However, it is unclear whether these reasoning strategies are explicitly used when families and medical providers are faced with acknowledging brain death. Their decisions are more likely to involve a prioritization of values and a rationalization of intuitive responses. Why and whether there might be differences between East and West in the acceptance of the brain death concept requires further empirical testing, which would help inform policy-making and facilitate communication between providers and patients from different cultural and ethnic backgrounds.

History of brain death as death: 1968 to the present

The concept of brain death was formulated in 1968 in the landmark report A Definition of Irreversible Coma. While brain death has been widely accepted as a determination of death throughout the world, many of the controversies that surround it have not been settled. Some may be rooted in a misconstruction about the history of brain death. The concept evolved as a result of the convergence of several parallel developments in the second half of the 20th century including advances in resuscitation and critical care, research into the underlying physiology of consciousness, and growing concerns about technology, medical futility, and the ethics of end of life care. Organ transplantation also developed in parallel, and though it clearly benefited from a new definition of death, it was not a principal driving force in its creation. Since 1968, the concept of brain death has been extensively analyzed, debated, and reworked. Still there remains much misunderstanding and confusion, especially in the general public. In this comprehensive review, I will trace the evolution of the definition of brain death as death from 1968 to the present, providing background, history and context.

Issues surrounding end-of-life decision-making

End-of-life decision-making is a complex process that can be extremely challenging. We describe a 42-year-old woman in an irreversible coma without an advance directive. The case serves to illustrate the complications that can occur in end-of-life decision-making and challenges in resolving difficult futility disputes. We review the role of advance directives in planning end-of-life care, the responsibility and historical performance of patient surrogates, the genesis of futility disputes, and approaches to resolving disputes.

Advanced technologies in trauma critical care management

Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care.

From intensive care to critical care medicine: a historical perspective

The evolution of Critical Care Medicine is traced in relationship to its predecessors, namely Intensive Care and Intensive Therapy. This commentary documents the initial physical care rendered by professional nurses in hospitals of the 19th century in locations close to the nursing stations. The development of incubators for newborns and life-support devices to support ventilation and renal function or to reverse fatal arrhythmias characterized Intensive Therapy of the early 20th century. In the most recent 50 years, Critical Care evolved for comprehensive, largely electronic monitoring and automated laboratory measurements to guide intensive therapy of multiorgan failures by critical care physicians and nurse specialists, pharmacists, and respiratory therapists using multiple life-support methodologies and devices.

Use of echocardiography and modalities of patient monitoring of trauma patients

PURPOSE OF REVIEW

Trauma patients require evaluation of the anatomic structure as well as the hemodynamic profile of the heart to improve effectiveness of resuscitation. They are prone to hemodynamic instability and must be monitored with various modalities to detect deterioration early. Newer, less invasive ultrasound technologies are replacing familiar 'gold standard' modalities of the past. This article reviews the indications, roles, imaging approaches, and limitations of modern echocardiography. A brief review of other ICU monitoring modalities is also presented.

RECENT FINDINGS

Echocardiography has emerged as a first-line diagnostic tool for assessment of trauma patients, especially those with hemodynamic compromise. It yields crucial information about structural damage as well as the hemodynamic profile and can be performed through either the transesophageal or transthoracic route. Quick and systematic use of echocardiography for diagnosis and management of critically injured patients may lead to improved outcomes.

SUMMARY

Echocardiography plays an important role in the trauma bay for diagnosis of thoracic injury and at the bedside in the ICU for evaluation of the hemodynamic profile.