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Challenges and Opportunities in Critical Care

Challenges and Opportunities in Critical Care

Aliaga, J., Ojeda, A., Comino-Trinidad, O., Cuñat, T., Arias, M., & Calvo, A. (2023)

Abstract

Introduction: The COVID-19 pandemic has resulted in a significant number of cases worldwide, leading to a substantial increase in Intensive care unit (ICU) admissions. Survivors of critical illness are known to experience long-term physical, cognitive, and psychological impairments. Chronic pain is also a prevalent complication, and specifically, neuropathic pain (NP) is strongly linked to a diminished quality of life. This narrative review aims to investigate the incidence, causes and manifestations of NP in critical illness COVID survivors.

Methods: A comprehensive search of the Pubmed database was conducted on May 31, 2023, using the keywords “Covid-19” OR “Sars-cov-2” combined with “neuropathic pain” and “critical care” OR “intensive care unit” to identify relevant publications in English or Spanish pertaining to adult human subjects. The search process adhered to the recommended flowchart format outlined in the PRISMA 2020 statement.

Results:  The primary search yielded 26 results. Eight results were excluded as they did not pertain to COVID-19 pain.

Discussion: Intensive care survivors can develop new onset pain and chronic pain though various mechanisms. In the case of critical illness COVID-19 survivors, pain may arise due to viral neurotropic potential, immune-mediated reactions, and microvascular complications. Studies have reported new-onset upper extremity NP, with ulnar neuropathy being the most prevalent, followed by brachial plexus, axillary, and median neuropathies. Lower limb NP particularly sciatic neuropathy has also been documented, along with peroneal nerve, meralgia paresthetica, and femoral neuropathy. Cranial neuropathies, such as facial palsy and trigeminal neuralgia, have been observed in case series. Additionally, widespread pain frequently associated with critical illness neuromyopathy may be present. Notably, COVID-19 survivors with critical illness may experience nociplastic pain and conditions related to central sensitization, posing challenges in distinguishing them from those with Long-COVID syndrome.

Conclusion: Further research is crucial to gain a comprehensive understanding of the neurological consequences arising from critical COVID-19 illness. Healthcare professionals should maintain a high suspicion index for NP in this population. Advancing our knowledge of NP in COVID-19 survivors can help develop effective strategies to enhance overall patient outcomes.

Kodama, C., Kuniyoshi, G., Obaid, B., Martinez, E., Heinzelmann, A., Moneim, A., Baraiah, S., Makki, A., Hashish, A., Alawi, K., Khawam, N., Jabbour, J., Abubakar, A., & Brennan, R. G. (2022)

Abstract

Background: Caring for critically ill patients is challenging in resource-limited and complex emergency settings such as Yemen, where the burden of disease and mortality from potentially treatable illnesses and injuries is higher than in resource-rich areas. Barriers to delivering quality critical care in these settings are numerous and include deficiencies in health systems structure, a limited capable healthcare workforce, insufficient financial resources, and access constraints due to insecurity, among many other factors. 

Methods: Potential solutions include the development of focused practical and educational programs for capacity building of national healthcare professionals’ knowledge and skill sets in the care of critically ill patients. This requires adaptation of proven curricula into a national training program to promote implementation of evidence-based critical care. 

Results: Yemen successfully introduced a 9-week national critical care training program that targeted both physicians and nurses from 11 of 12 southern governorates from 5th June to 11th August 2022. The procedures for its development and its implementation are described in this report. Successful continued development and implementation are contingent on ongoing adaptation, secured financial resources, and support from academic institutions such as the Faculty of Medicine and Health Sciences University of Aden (Yemen), the Oman Medical Specialty Board (Sultanate of Oman), health care authorities and partners. Technologies utilized included tele-education and a simulation skills center using high fidelity manikins, in addition to the lectures and bed-side training sessions in Intensive Care Unit (ICU). 

Conclusion: Critical care training is a vital need and of paramount importance in resource-limited and complex emergency settings such as Yemen and programs should be developed and sustained under country ownership with support from internal and external partners. The current challenges and shortfalls require new approaches such as a comprehensive, focused critical care/ICU national training program to build a cadre of critical care professionals in the country together with the provision of human, material, and financial resources support. Through producing a cadre of critical care/ICU national professionals, this course is contributing to enhancing the emergency preparedness and response capacities in Yemen, as well as building sustainable critical care capabilities within the national health system that will further save many lives in Yemen.

Jr, M., Tebar, G., Salgueiro, J., Galindo, G., Hughes, J. L., Sayari, A. A., Soucy, E., & Mohseni, S. (2023)

Abstract

Trauma surgery is traditionally carried out through open procedures; however, the use of laparoscopy in stable patients has been gaining room due to favorable outcomes reported in different studies available in the literature. Nowadays, laparoscopy applied to trauma cases can be divided into screening, diagnosis, and therapeutic applications. Laparoscopic surgery application was initially limited to screening procedure focused on finding peritoneal violations; such a procedure would be followed by exploratory laparotomy. The benefits of using laparoscopy in trauma cases as diagnostic tool to rule out intra-abdominal injuries that may have gone unnoticed in computed tomography, such as diaphragmatic injuries can be easily seen. It can be used to prevent unnecessary laparotomies in patients with penetrating injuries, whose fascial breach cannot be clinically or radiologically ruled out. This paper describes the current indications for the use of laparoscopy in trauma, its potential benefits as well as complications related to the technique. We highlight and describe the importance of systematization for investigation of the peritoneal cavity as well as the expansion of indications for treatment of certain lesions by exclusive laparoscopic approach. This is due to the development of equipment as well as a greater number of surgeons trained in advanced laparoscopic surgery. We also present the main potential complications related to the method as well as the limitations still encountered today.

Oa, O., Akhideno, I., Fagbohun, O., & Ogunjuboun, A. (2023)

Abstract

The novel Coronavirus disease-19, caused by the Severe Acute Respiratory Syndrome-Coronavirus-2 virus posed a worldwide public health emergency and remains a large health burden till date in some continents, causing a significant morbidity and mortality among the critically-ill, not sparing the low and medium-income countries. The critical care surge in most countries exposed the unpreparedness and “struggling” health systems of these countries, including Low and medium-income countries in containing the epidemic. The suddenness of Coronavirus disease in China is suggestive that another “Pathogen X” epidemic may occur. In addition, the increasing global terrorism index may precipitate another epidemic secondary to a bioterrorism contagion. In mitigating this, however, lessons learnt from the management of the critically-ill patients with the Coronavirus disease may assist the low and medium-income countries in charting the future directions of critical care in the event of any Post Coronavirus disease public health challenge. The import of systems approach and collaboration with development partners cannot be over-emphasized, alongside increasing critical care beds and improving oxygen availability and accessibility. Finally, changing the narrative of “struggling” health systems of developing countries by addressing the major debilitating factors, including the issue of critical care workforce and training is needed. The new Essential and Emergency Critical Care training program is proffered. Furthermore, offering skilled healthcare workers adequate remuneration and other incentives to guard against their migration to “greener pastures” may help the low and middle-income countries retain critical care specialists in preparing for any sudden Post-Coronavirus disease public health emergency.

Bunin, J., Varpio, L., & Meyer, H. (2023)

Abstract

Introduction: Empathy improves patient outcomes and increases perception of physician competence. However, empathy may contribute to biased decision-making and provider burnout. To help providers harness the benefits of empathy without the pitfalls, comprehensive knowledge about the practice of empathy is needed – particularly in high-stress contexts, such as in critical care. This qualitative study explores how critical care physicians experience empathy in intensive care units and how this might inform the medical education of critical care physicians throughout their training.

Methods: Working from a constructivist orientation, we engaged in thematic analysis of semi-structured interviews with critical care physicians. We asked participants to describe their personal experiences of empathy including how they handled events requiring empathy, managed empathic distress, and reframed their understanding of empathy over time. Data analysis followed the six steps of thematic analysis and used Hoffman’s Theory of Empathy to further inform our understanding of the data.

Results: We identified limitations of empathy in the intensivist experience, which were consistent with Hoffman’s theory of empathy. This theory describes arousal, habituation, and bias which were prevalent in the data. Further, intensivists altered their behavior due to these limitations and to manage empathic distress. Additionally, burnout as a consequence of empathy was identified, though interviewees discussed prevention methods and the development of resilience.

Discussion: Empathy and empathic distress among intensivists have been understudied in the literature thus far. Our study reveals that critical care physicians acutely experience limitations of empathy to include over-arousal, habituation, and bias—all of which impact interactions with patients, physician stress, and physician burnout. The knowledge that fully trained intensivists struggle with the limitations of empathy has implications to all stages of physician education from medical student through continuing medical education for attendings since all must learn and practice the empathic skills required to optimize patient care and maintain their own wellness.

Huq, S. M. R., Ahmed, R., Ahmed, M., Rabbani, R., Hasan, J., & Anam, A. (2022)

Abstract

Baricitinib is an oral selective Janus kinase 1 and 2 inhibitor with known anti-inflammatory and anti-viral properties. In patients hospitalized for coronavirus disease 2019 (COVID-19), baricitinib has shown to reduce the risk of death in line with dexamethasone and tocilizumab. However, the most effective and safe dose or optimal dose of baricitinib in severe COVID-19 was not addressed.

We conducted this systematic review to assess whether higher than usual dose could further improve survival as primary outcome. The need of ICU (Intensive care Unit) and Invasive or non-invasive positive pressure ventilation, time to wean from oxygen, length of stay at hospital and adverse events were analyzed as secondary outcome.

We included 10,032 patients in 5 studies (2 randomised control trials and 3 high quality clinical trials). Among them,5,071 patients received baricitinib at different dosage (4909 patients received 4 mg once daily and 162 patients got more than 4 mg daily) and 4961 received standard of care. Baseline characteristics including mean age, sex, co-morbidities, inflammatory marker (C-reactive protein/CRP) were similar across the intervention and standard care groups.

4 out of 5 trials showed significant survival benefit in baricitinib group usual to higher dose (4 to 8 mg daily). Use of higher dose in 3 controlled trials was associated with significant reduction in admission to ICU and requirement of invasive or non-invasive ventilation support, shortening of hospital stay and earlier stabilization of oxygen status which was not evident in two randomized control trials using usual dose (4 mg daily). There was no significant difference in any serious adverse events or opportunistic infections between higher dose versus usual dose group.

Therefore, baricitinib in higher dose could be a potent, highly effective and safe immunomodulatory drug in hospitalized patients with severe COVID-19.

Filho, R. K. (2024)

Abstract

Since the advent of intensive care units in the twentieth century, several advances have been developed in relation to diagnosis, organ support, and treatment modalities. However, the environment for professionals, patients and their families continues to be stressful and uncomfortable. Optimizing the working conditions and processes of intensive care units is of great significance for improving efficiency and minimizing human errors. Innovations and technological advances can also bring higher quality and safer medicine, as well as greater personalization and a better experience for critically ill patients. This article reviews the progress in the related fields that could be the trend in the coming years for the formation of intelligent intensive care units. It is discussed how thinking about design, structure, equipment, less invasive monitoring, expansion of digital transformation, incorporation of artificial intelligence, in addition to the perspectives of these changes on the multidisciplinary team, can be important in the search for patient-centered care in the future of the intensive care units.

Bayon, C., Detollenaere, C., Favory, R., & Decrucq, E. (2023)

Abstract

What is already known

Clinical features have also been described as predictors for poor outcomes: initial fever is associated with an increased risk of hospitalization, but does not seem to be a discriminating factor in the development of critical illness. Initial dyspnea is linked to severe and critical forms and digestive symptoms are associated with severe forms. Only hypoxemia was a predictor for mechanical ventilation in the first 48 hours. Yet many hypoxemic patients show very few signs of respiratory distress, as in « silent hypoxemia ».

What is new in the current study

The clinical assessment of respiratory mechanics is one of the best ways to predict the need for invasive ventilation. Deferring intubation in patients at very high risk of requiring mechanical ventilation could deteriorate respiratory status and lead to increased ventilatory difficulties following intubation.

ABSTRACT

Object: Since it began in Wuhan in December 2019, the Coronavirus Disease pandemic has affected more than 500 million people and caused more than 6 million deaths. Identifying risk factors for severe cases has become a major issue. We evaluated whether patient characteristics upon intensive care unit admission could predict later intubation. We also compared outcomes for patients undergoing early versus delayed intubation.

Methods: This is a retrospective, monocentric study carried out in a medical university intensive care unit between August 2020 and January 2021. Demographic, clinical, biological and imaging data were collected (on arrival and on day 2). We examined intubation timing (before or after 48h hours after intensive care unit admission), ventilatory features and outcomes for intubated patients.

Results: SAPS2, high steroid dosages, pulmonary superinfection, extensive CT pulmonary lesions, polypnea and elevated oxygen requirements were associated with a higher need of intubation. Biological features on admission were non-discriminatory. Delayed intubation seemed to be associated with more severe acute respiratory distress syndrome, but mortality did not vary.

Discussion and conclusion: Intubation can be predicted using a multimodal approach including clinical and imaging features. Early clinical evaluation plays a key role in identifying patients likely to be intubated. Delaying intubation could lead to respiratory worsening.

Lee, K., & Loke, J. (2023)

Abstract

Background: Obtaining appointments at a general practice was critical for reducing avoidable hospital admissions, and ultimately saving healthcare costs. In the United Kingdom (UK), problematic access of appointments at individual general practices persisted resulting from increasing health complexities in primary care, which were exacerbated by shortages of medical doctors as general practitioners (GP). The UK government pursued the employing of care-coordinators at primary care networks to allocate care to non-GP health professionals as a solution, but patient demand for GP appointments at individual practices continued to surge.

Aims: This paper reports on an investigation of the ideal way to address patient demand on GP appointments at individual practices. It aimed to report on the effects of two newly implemented joint consultations, one comprising a nursing team and another, a multi-disciplinary team comprising medical doctors and nursing personnel.

Methods: Three reviews were conducted in a 3500 patient-list-sized GP practice located in North-Eastern part of England. The aim was to analyse retrospective data of the telephony system to explore the effect of joint consultations on demand of GP appointments that were made through the telephony system. The number and lengths of incoming telephone calls to secure GP or nursing appointments at the practice were analysed descriptively. The periods of analysis were from January to August in the years 2021, 2022 and 2023.

Results: Since implementation of the two joint consultations, there was a 32% reduction in telephone calls for GP appointments. There was also a shortening of the duration of these telephone calls and decreasing trends of missed calls. The increased lengths of calls towards the tail end of the 3rd review period in 2023 demonstrated increased patient awareness and cooperation for in-depth discussions about their symptoms prior to securing appointments.

Conclusions: The joint consultations had significantly decreased patient demands for GP appointments via telephone. In addition, the joint consultations had not only allowed holistic care needs to be addressed, but also, they had permitted appropriate care to be delivered in a timely fashion. It is therefore important to ensure appropriate healthcare funding to support the implementation of joint consultations at individual GP practices.

Swami, M., & Provost, K. (2023)

Abstract

Breathlessness is a distressing symptom, uniformly faced at some point in the disease process in all patients with Chronic Obstructive Pulmonary Disease (COPD). Despite maximal medical therapy and pulmonary rehabilitation, patients with COPD continue to experience refractory dyspnea, pain, poor appetite, limitations of physical activity, emotional distress, depression and overall poor health-related quality of life. Our current GOLD ABE pharmacologic treatment algorithm provides maximal disease specific therapy directed at optimization of physiologic airflow obstruction and exacerbation frequency, however leaving a gap in how best to approach the complex and multifactorial symptom of refractory breathlessness that occurs despite these pharmacologic interventions and pulmonary rehabilitation. The comprehensive and multidisciplinary approach of specialty palliative care may well fill this gap in our treatment algorithms. In this review, we will review the growing body of literature on the definitions and role of primary and specialty palliative care in the treatment of patients with COPD, review the components of a structured palliative care intervention in advanced lung disease, review the current pharmacologic and non-pharmacologic treatments for breathlessness, the identified barriers to palliative care intervention and consider the future direction of palliative care engagement in patients with COPD.

Bou-Ouhrich, Y., & Чарра, Б. (2022)

Abstract

Introduction: Thrombocytopenia is a platelet count below 150,000/mm3. It is a frequent abnormality in critically ill patients.

Methods: We conducted a retrospective study which included 603 patients admitted to the medical intensive care unit in the Ibn Rochd university hospital of Casablanca over a two years period, from January 1, 2018 to December 31, 2019. The aim of the study is to point out the incidence, risk factors, etiologies, therapeutic modalities, as well as the morbidity and mortality related to thrombocytopenia in critical care.

Results: During the study period, and out of these 603 patients, 168 patients had thrombocytopenia, that is an incidence of 27.8%; 38 patients among them were admitted with an already ongoing thrombocytopenia. Sepsis, Acute respiratory distress syndrome, renal failure, hemodialysis, and liver dysfunction were risk factors of thrombocytopenia and predictors of mortality. Thrombocytopenia was a factor of increased mortality, the percentage of death was higher in the thrombocytopenic group compared with the non-thrombocytopenic group with a rate of 42.26%. However, it was not an independent factor of mortality.

Conclusion: Sepsis is the major factor incriminated in the occurrence of thrombocytopenia in critically ill patients. Therapeutic management including platelet transfusion should depend on the etiology of thrombocytopenia along with the associated hemorrhagic risk.

Urada, L. A., McClung, M., Brocklin, R., & Blumenthal, J. (2022)

Abstract

Background: Peer navigation is an evidence-based model for engaging and retaining women living with HIV in medical care. Participants of an adapted Lotus peer navigation group intervention were hypothesized to have more self-perceived HIV self-care and advocacy behaviors following their participation than non-Lotus participants at an agency serving cisgender women and their families affected by HIV in San Diego, California.

Methods: The peer navigation intervention, Lotus, was adapted to include new modules on substance use, human trafficking, and intimate partner violence and piloted to compare its overall effects with a comparison group (2018-2019). Ninety-five cisgender women living with HIV (WLWH) completed posttest surveys measuring their perceived changes in peer advocacy and self-advocacy following their participation in a pilot of an adapted Lotus. Participants of the four-session Lotus group intervention (n=34) were compared to non-Lotus participants who engaged in other types of group activities at the agency (n=61). The Lotus group participants included a cohort of cisgender women > 50 years old, English and Spanish speaking women, and a mixed age and race/ethnicity group. All clients of Christie’s Place, an organization for women living with HIV in San Diego, were eligible if they were not actively using illicit substances substances in the past year. Cross-sectional bivariate analyses were run to determine differences between intervention and comparison groups. The groups were not randomized.

Results: Among 95 participants, 17% were White, 14% Black/African American, 44% Hispanic/Latino, and 25% Other/Mixed race/ethnicity with median age 51 years (IQR: 45-60). Eleven Latina, 9 White, 6 Black/African American, and 8 Other/Mixed individuals participated in Lotus. In bivariate analyses, Lotus WLWH living with HIV at posttest took their HIV medications correctly (p=0.040) and attended their healthcare/other service appointments as advised/scheduled 3 times more often than non-Lotus WLWH (p=0.014). They advocated for themselves within medical and social service settings 6 times more often (p<0.001) and talked openly with their doctor 4 times more often (p=0.028). They were also twice as likely to talk more often with their partner about safer sex (p=0.022) and PrEP (p=0.037) and a peer about safer sex (p=0.001). They were 3 times more likely to help a peer understand how HIV medications can improve their health (p=0.001). Medical records showed all Lotus intervention participants as virally suppressed one year after their participation.

Conclusions: Participants of an HIV peer navigation intervention experienced significant changes in self-reported self-advocacy outcomes. Peer navigation training interventions remain critical for medication adherence and self-advocacy among cisgender WLWH.

Beuret, P., & Veislinger, G. (2022)

Abstract

Most patients admitted to the intensive care unit are unable to participate in decisions relating to their care. Therefore, physicians have to inform relatives on the condition of the patient, his evolution and the estimated prognosis. Numerous studies have shown that relatives commonly have inaccurate expectations of the patient’s prognosis, due to either misunderstanding of oral information by the physicians and/or overly optimistic beliefs. This may lead to undue prolongation of an ICU stay in the case of a poor prognosis. Several methods have been proposed in order to align relatives with the estimation of the patient’s prognosis by the physicians. The use of visual tools, added to oral information seems beneficial. Moreover, communication with relatives on the prognosis has to convey support and empathy.