Virtual and augmented reality in intensive care medicine: a systematic review

Efficacy and safety of a non-immersive virtual reality-based neuropsychological intervention for cognitive stimulation and relaxation in patients with critical illness: study protocol of a randomized clinical trial (RGS-ICU)

BACKGROUND

Experiencing a critical illness may be a stressful life event that is also associated with cognitive dysfunction during and after the intensive care unit (ICU) stay. A deep-tech solution based on non-immersive virtual reality, gamification and motion capture called Rehabilitation Gaming System for Intensive Care Units (RGS-ICU) has been developed that includes both cognitive stimulation and relaxation protocols specifically designed for patients with critical illness. This study aims to evaluate whether the cognitive and relaxation protocols of the RGS-ICU platform are 1) effective in improving neuropsychological outcomes during and after ICU stay and 2) safe for patients with critical illness.

METHODS

This is a study protocol for a multicenter longitudinal randomized clinical trial. At least 80 patients with critical illness will be included: 40 experimental subjects and 40 control subjects. Patients in the experimental group will receive daily 20-min sessions of cognitive stimulation and relaxation with the RGS-ICU platform adjuvant to standard ICU care in their own rooms during the ICU stay and until discharge from the ICU or up to a maximum of 28 days after randomization, provided they are alert and calm. Patients in the experimental group will be constantly monitored as part of standard ICU care to ensure the safety of the intervention and that no avoidable adverse events occur. Patients in the control group will receive standard ICU care. The primary outcome is objective cognition 12 months after ICU discharge, assessed with a composite index including measures of attention, working memory, learning/memory, executive function and processing speed. The secondary outcome is the safety of the intervention, assessed by considering the number of sessions terminated early due to unsafe events in physiological parameters. Other outcomes are comfort experienced during the ICU stay, and subjective cognition, mental health (anxiety, depression and post-traumatic stress disorder), functionality and health-related quality of life 12 months after ICU discharge.

DISCUSSION

The expected results are 1) better neuropsychological outcomes during and after the ICU stay in patients in the experimental group compared to patients in the control group and 2) that the cognitive and relaxation protocols of the RGS-ICU platform are safe for patients with critical illness.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06267911. Registered on February 20, 2024.

Reporting Guidelines for the Early-Phase Clinical Evaluation of Applications Using Extended Reality: RATE-XR Qualitative Study Guideline

BACKGROUND

Extended reality (XR), encompassing technologies such as virtual reality, augmented reality, and mixed reality, has rapidly gained prominence in health care. However, existing XR research often lacks rigor, proper controls, and standardization.

OBJECTIVE

To address this and to enhance the transparency and quality of reporting in early-phase clinical evaluations of XR applications, we present the "Reporting for the early-phase clinical evaluation of applications using extended reality" (RATE-XR) guideline.

METHODS

We conducted a 2-round modified Delphi process involving experts from diverse stakeholder categories, and the RATE-XR is therefore the result of a consensus-based, multistakeholder effort.

RESULTS

The guideline comprises 17 XR-specific (composed of 18 subitems) and 14 generic reporting items, each with a complementary Explanation & Elaboration section.

CONCLUSIONS

The items encompass critical aspects of XR research, from clinical utility and safety to human factors and ethics. By offering a comprehensive checklist for reporting, the RATE-XR guideline facilitates robust assessment and replication of early-stage clinical XR studies. It underscores the need for transparency, patient-centeredness, and balanced evaluation of the applications of XR in health care. By providing an actionable checklist of minimal reporting items, this guideline will facilitate the responsible development and integration of XR technologies into health care and related fields.

Authentic assessment in medical education: exploring AI integration and student-as-partners collaboration

BACKGROUND

Traditional assessments often lack flexibility, personalized feedback, real-world applicability, and the ability to measure skills beyond rote memorization. These may not adequately accommodate diverse learning styles and preferences, nor do they always foster critical thinking or creativity. The inclusion of Artificial Intelligence (AI), especially Generative Pre-trained Transformers, in medical education marks a significant shift, offering both exciting opportunities and notable challenges for authentic assessment practices. Various fields, including anatomy, physiology, pharmacy, dentistry, and pathology, are anticipated to employ the metaverse for authentic assessments increasingly. This innovative approach will likely enable students to engage in immersive, project-based learning experiences, facilitating interdisciplinary collaboration and providing a platform for real-world application of knowledge and skills.

METHODS

This commentary paper explores how AI, authentic assessment, and Student-as-Partners (SaP) methodologies can work together to reshape assessment practices in medical education.

RESULTS

The paper provides practical insights into effectively utilizing AI tools to create authentic assessments, offering educators actionable guidance to enhance their teaching practices. It also addresses the challenges and ethical considerations inherent in implementing AI-driven assessments, emphasizing the need for responsible and inclusive practices within medical education. Advocating for a collaborative approach between AI and SaP methodologies, the commentary proposes a robust plan to ensure ethical use while upholding academic integrity.

CONCLUSION

Through navigating emerging assessment paradigms and promoting genuine evaluation of medical knowledge and proficiency, this collaborative effort aims to elevate the quality of medical education and better prepare learners for the complexities of clinical practice.

Using augmented intelligence to improve long term outcomes

PURPOSE OF REVIEW

For augmented intelligence (AI) tools to realize their potential, critical care clinicians must ensure they are designed to improve long-term outcomes. This overview is intended to align professionals with the state-of-the art of AI.

RECENT FINDINGS

Many AI tools are undergoing preliminary assessment of their ability to support the care of survivors and their caregivers at multiple time points after intensive care unit (ICU) discharge. The domains being studied include early identification of deterioration (physiological, mental), management of impaired physical functioning, pain, sleep and sexual dysfunction, improving nutrition and communication, and screening and treatment of cognitive impairment and mental health disorders.Several technologies are already being marketed and many more are in various stages of development. These technologies mostly still require clinical trials outcome testing. However, lacking a formal regulatory approval process, some are already in use.

SUMMARY

Plans for long-term management of ICU survivors must account for the development of a holistic follow-up system that incorporates AI across multiple platforms. A tiered post-ICU screening program may be established wherein AI tools managed by ICU follow-up clinics provide appropriate assistance without human intervention in cases with less pathology and refer severe cases to expert treatment.

Care Beyond Cure: Humanizing the Intensive Care Unit Journey

How to cite this article: Chacko B. Care Beyond Cure: Humanizing the Intensive Care Unit Journey. Indian J Crit Care Med 2024;28(10):901-902.

Virtual reality as a promising method of pain relief in patients with venous leg ulcers

Pain in patients suffering from hard-to-heal wounds is a serious problem that hinders the healing process and affects their quality of life. Virtual reality (VR) is increasingly being used for pain relief. The aim of the study was to assess whether the use of VR during mechanical cleansing of venous leg ulcers would result in a reduction in patients' pain. Sixty patients were randomly divided into two groups. The experimental group included patients who used VR goggles during wound cleansing, and the control group included patients who did not use such equipment during wound cleansing. The Oculus Quest 2 VR Goggles were used in the experiment. After wound cleaning, the patient assessed the intensity of his pain on a numerical pain rating scale from 0 to 10 points. The difference between the intensity of pain during wound cleansing in patients from the experimental and control group turned out to be statistically significant (p < 0.001). It was on average 1.13 ± 0.68 points in the experimental group, and in the case of people from the control group, it was 4.73 ± 1.2 points. To conclude, the use of VR in patients with venous leg ulcers reduces pain during wound cleansing.

Theory-based and evidence-based nursing interventions for the prevention of ICU-acquired weakness in the intensive care unit: A systematic review

OBJECTIVES

To synthesise and map the evidence of a theory- and evidence-based nursing intervention for the prevention of ICU-acquired weakness and evaluate its effectiveness in terms of the incidence of ICU-acquired weakness, incidence of delirium, and length of hospital stay.

METHODS

We searched PubMed, CINAHL, MEDLINE, Academic Search Complete, Embase, Scopus, Web of Science and the Cochrane Library from database inception to November 2023. The eligible studies focused on critically ill patients in the intensive care unit, used a theory- and evidence-based nursing intervention, and reported the incidence of ICU-acquired weakness and/or used the Medical Research Council Scale. The methodological quality of the included studies was critically appraised by two authors using the appropriate Joanna Briggs Institute appraisal tool for randomised controlled trials, quasi-experimental studies, and cohort studies. Additionally, the weighted kappa coefficient was used to assess inter-rater agreement of the quality assessment. Data were reported using a narrative synthesis. This systematic review was registered by the International Prospective Register of Systematic Review (PROSPERO; CRD42023477011).

RESULTS

A total of 5162 studies were initially retrieved, and 9 studies were eventually included after screening. This systematic review revealed that preventive nursing interventions for ICU-acquired weakness mainly include (a) physiotherapy, including neuromuscular electrical stimulation and early rehabilitation, and (b) nutritional support. In addition, (c) airway management, (d) sedation and analgesia management, (e) complication prevention (delirium, stress injury and deep vein thrombosis prevention), and (f) psychological care were also provided. The theories are dominated by goal-oriented theories, and the evidence is mainly the ABCDE bundle in the included studies. The results show that theory- or evidence-based nursing interventions are effective in reducing the incidence of ICU-acquired weakness (or improving the Medical Research Council Scale scores), decreasing the incidence of delirium, shortening the length of hospital stay, and improving patients' self-care and quality of life.

CONCLUSION

Theory- and evidence-based nursing interventions have good results in preventing ICU-acquired weakness in critically ill patients. Current nursing interventions favour a combination of multiple interventions rather than just a single intervention. Therefore, preventive measures for ICU-acquired weakness should be viewed as complex interventions and should be based on theory or evidence. This systematic review is based on a small number of trials. Thus, more high-quality randomised controlled trials are needed to draw definitive conclusions about the impact of theory- and evidence-based nursing interventions on the prevention of ICU-acquired weakness.

Augmented reality- virtual reality wartime training of reserve prehospital teams: a pilot study

BACKGROUND

In the realm of trauma response preparation for prehospital teams, the combination of Augmented Reality (AR) and Virtual Reality (VR) with manikin technologies is growing in importance for creating training scenarios that closely mirror potential real-life situations. The pilot study focused on training of airway management and intubation for trauma incidents, based on a Trauma AR-VR simulator involving reserve paramedics of the National EMS service (Magen David Adom) who had not practiced for up to six years, activated during the Israel-Gaza conflict (October 2023). The trauma simulator merges the physical and virtual realms by utilizing a real manikin and instruments outfitted with sensors. This integration enables a precise one-to-one correspondence between the physical and virtual environments. Considering the importance of enhancing the preparedness of the reserve paramedics to support the prehospital system in Israel, the study aims to ascertain the impact of AR-VR Trauma simulator training on the modification of key perceptual attitudes such as self-efficacy, resilience, knowledge, and competency among reserve paramedics in Israel.

METHODS

A quantitative questionnaire was utilized to gauge the influence of AR-VR training on specific psychological and skill-based metrics, including self-efficacy, resilience, medical knowledge, professional competency, confidence in performing intubations, and the perceived quality of the training experience in this pilot study. The methodology entailed administering a pre-training questionnaire, delivering a targeted 30-minute AR-VR training session on airway management techniques, and collecting post-training data through a parallel questionnaire to measure the training's impact. Fifteen reserve paramedics were trained, with a response rate of 80% (n = 12) in both measurements.

RESULTS

Post-training evaluations indicated a significant uptick in all measured areas, with resilience (3.717±0.611 to 4.008±0.665) and intubation confidence (3.541±0.891 to 3.833±0.608) showing particularly robust gains. The high rating (4.438±0.419 on a scale of 5) of the training quality suggests positive response to the AR-VR integration for the enhancement of medical training, CONCLUSIONS: The application of AR-VR in the training of reserve paramedics demonstrates potential as a key tool for their swift mobilization and efficiency in crisis response. This is particularly valuable for training when quick deployment of personnel is necessary, training resources are diminished, and 'all hands on deck' is necessary.

Device associated complications in the intensive care unit

Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit.

Exploring Augmented Reality Integration in Diagnostic Imaging: Myth or Reality?

This study delves into the transformative potential of integrating augmented reality (AR) within imaging technologies, shedding light on this evolving landscape. Through a comprehensive narrative review, this research uncovers a wealth of literature exploring the intersection between AR and medical imaging, highlighting its growing prominence in healthcare. AR's integration offers a host of potential opportunities to enhance surgical precision, bolster patient engagement, and customize medical interventions. Moreover, when combined with technologies like virtual reality (VR), artificial intelligence (AI), and robotics, AR opens up new avenues for innovation in clinical practice, education, and training. However, amidst these promising prospects lie numerous unanswered questions and areas ripe for exploration. This study emphasizes the need for rigorous research to elucidate the clinical efficacy of AR-integrated interventions, optimize surgical workflows, and address technological challenges. As the healthcare landscape continues to evolve, sustained research efforts are crucial to fully realizing AR's transformative impact in medical imaging. Systematic reviews on AR in healthcare also overlook regulatory and developmental factors, particularly in regard to medical devices. These include compliance with standards, safety regulations, risk management, clinical validation, and developmental processes. Addressing these aspects will provide a comprehensive understanding of the challenges and opportunities in integrating AR into clinical settings, informing stakeholders about crucial regulatory and developmental considerations for successful implementation. Moreover, navigating the regulatory approval process requires substantial financial resources and expertise, presenting barriers to entry for smaller innovators. Collaboration across disciplines and concerted efforts to overcome barriers will be essential in navigating this frontier and harnessing the potential of AR to revolutionize healthcare delivery.

Semiconducting polymer dots for multifunctional integrated nanomedicine carriers

The expansion applications of semiconducting polymer dots (Pdots) among optical nanomaterial field have long posed a challenge for researchers, promoting their intelligent application in multifunctional nano-imaging systems and integrated nanomedicine carriers for diagnosis and treatment. Despite notable progress, several inadequacies still persist in the field of Pdots, including the development of simplified near-infrared (NIR) optical nanoprobes, elucidation of their inherent biological behavior, and integration of information processing and nanotechnology into biomedical applications. This review aims to comprehensively elucidate the current status of Pdots as a classical nanophotonic material by discussing its advantages and limitations in terms of biocompatibility, adaptability to microenvironments in vivo, etc. Multifunctional integration and surface chemistry play crucial roles in realizing the intelligent application of Pdots. Information visualization based on their optical and physicochemical properties is pivotal for achieving detection, sensing, and labeling probes. Therefore, we have refined the underlying mechanisms and constructed multiple comprehensive original mechanism summaries to establish a benchmark. Additionally, we have explored the cross-linking interactions between Pdots and nanomedicine, potential yet complete biological metabolic pathways, future research directions, and innovative solutions for integrating diagnosis and treatment strategies. This review presents the possible expectations and valuable insights for advancing Pdots, specifically from chemical, medical, and photophysical practitioners' standpoints.

Virtual Reality for Cardiopulmonary Resuscitation Healthcare Professionals Training: A Systematic Review

INTRODUCTION

Virtual reality (VR) is becoming increasingly popular to train health-care professionals (HCPs) to acquire and/or maintain cardiopulmonary resuscitation (CPR) basic or advanced skills.

AIM

To understand whether VR in CPR training or retraining courses can have benefits for patients (neonatal, pediatric, and adult), HCPs and health-care organizations as compared to traditional CPR training.

METHODS

A systematic review (PROSPERO: CRD42023431768) following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. In June 2023, the PubMed, Cochrane Library, Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched and included studies evaluated in their methodological quality with Joanna Briggs Institute checklists. Data were narratively summarized.

RESULTS

Fifteen studies published between 2013 and 2023 with overall fair quality were included. No studies investigated patients' outcomes. At the HCP level, the virtual learning environment was perceived to be engaging, realistic and facilitated the memorization of the procedures; however, limited decision-making, team building, psychological pressure and frenetic environment were underlined as disadvantages. Moreover, a general improvement in performance was reported in the use of the defibrillator and carrying out the chest compressions. At the organizational level, one study performed a cost/benefit evaluation in favor of VR as compared to traditional CPR training.

CONCLUSIONS

The use of VR for CPR training and retraining is in an early stage of development. Some benefits at the HCP level are promising. However, more research is needed with standardized approaches to ensure a progressive accumulation of the evidence and inform decisions regarding the best training methodology in this field.

Immersive Innovations: Exploring the Diverse Applications of Virtual Reality (VR) in Healthcare

Virtual reality (VR) has experienced a remarkable evolution over recent decades, evolving from its initial applications in specific military domains to becoming a ubiquitous and easily accessible technology. This thorough review delves into the intricate domain of VR within healthcare, seeking to offer a comprehensive understanding of its historical evolution, theoretical foundations, and current adoption status. The examination explores the advantages of VR in enhancing the educational experience for medical students, with a particular focus on skill acquisition and retention. Within this exploration, the review dissects the applications of VR across diverse medical disciplines, highlighting its role in surgical training and anatomy/physiology education. While navigating the expansive landscape of VR, the review addresses challenges related to technology and pedagogy, providing insights into overcoming technical hurdles and seamlessly integrating VR into healthcare practices. Additionally, the review looks ahead to future directions and emerging trends, examining the potential impact of technological advancements and innovative applications in healthcare. This review illuminates the transformative potential of VR as a tool poised to revolutionize healthcare practices.

RiNeo MR: A mixed reality simulator for newborn life support training

Neonatal resuscitation is an uncommon, albeit critical task that is more likely to succeed if performed properly and promptly. In this context, simulation is an appropriate way for training and assessing the abilities of all medical staff involved in delivery room care. Recent studies have shown that learning is enhanced if the simulation experience is realistic and engaging. Hence, Virtual Reality can be beneficial for newborn resuscitation training. However, the difficulty of providing realistic haptic interaction limits its use. To overcome this constraint, we have designed RiNeo MR, a simulator for newborn life support training, combining a sensorized manikin to monitor in real time resuscitation skills, with a Virtual Reality application. The system includes a Virtual Reality headset, Leap Motion to track the user's hands, sensorized bag valve mask, and manikin to monitor head and mask positioning, ventilation, and chest compression. RiNeo MR can be used in two modalities: 2D to let the trainee practice resuscitation manoeuvres on the physical manikin, while receiving real time feedback; 3D that allows the user to be immersed in a virtual environment and practice in an hospital-like setting. In the 3D mode, virtual and real manikins are overlapped and communicate in real time. Tests on 16 subjects (11 controls without medical expertise and 5 paediatric residents) demonstrated that the simulator is well tolerated in terms of discomfort. Moreover, the simulator is high rated for user experience and system usability, suggesting that RiNeo MR can be a promising tool to improve newborn life support training. RiNeo MR is a proof of concept of a mixed-reality newborn life support simulator that can be a promising tool to spread newborn resuscitation high-quality training among healthcare providers involved in perinatal medicine.