Future of neurocritical care:Integrating neurophysics,multimodal monitoring,and machine learning

Multimodal monitoring(MMM)in the intensive care unit(ICU)has become increasingly sophisticated with the integration of neurophysical principles.However,the challenge remains to select and interpret the most appropriate combination of neuromonitoring modalities to optimize patient outcomes.This manuscript reviewed current neuromonitoring tools,focusing on intracranial pressure,cerebral electrical activity,metabolism,and invasive and noninvasive autoregulation moni-toring.In addition,the integration of advanced machine learning and data science tools within the ICU were discussed.Invasive monitoring includes analysis of intracranial pressure waveforms,jugular venous oximetry,monitoring of brain tissue oxygenation,thermal diffusion flowmetry,electrocorticography,depth electroencephalography,and cerebral microdialysis.Noninvasive measures include transcranial Doppler,tympanic membrane displacement,near-infrared spectroscopy,optic nerve sheath diameter,positron emission tomography,and systemic hemodynamic monitoring including heart rate variability analysis.The neurophysical basis and clinical relevance of each method within the ICU setting were examined.Machine learning algorithms have shown promise by helping to analyze and interpret data in real time from continuous MMM tools,helping clinicians make more accurate and timely decisions.These algorithms can integrate diverse data streams to generate predictive models for patient outcomes and optimize treatment strategies.MMM,grounded in neurophysics,offers a more nuanced understanding of cerebral physiology and disease in the ICU.Although each modality has its strengths and limitations,its integrated use,especially in combination with machine learning algorithms,can offer invaluable information for individualized patient care.

21st century critical care medicine:An overview

Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units(ICUs).This abstract provides a concise summary of the latest developments in critical care,highlighting key areas of innovation.Recent advancements in critical care include Precision Medicine:Tailoring treatments based on individual patient characteristics,genomics,and biomarkers to enhance the effectiveness of therapies.The objective is to describe the recent advancements in Critical Care Medicine.Telemedicine:The integration of telehealth technologies for remote patient monitoring and consultation,facilitating timely interventions.Artificial intelligence(AI):AI-driven tools for early disease detection,predictive analytics,and treatment optimization,enhancing clinical decision-making.Organ Support:Advanced life support systems,such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support.Infection Control:Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections.Ventilation Strategies:Precision ventilation modes and lung-protective strategies to minimize ventilatorinduced lung injury.Sepsis Management:Early recognition and aggressive management of sepsis with tailored interventions.Patient-Centered Care:A shift towards patient-centered care focusing on psychological and emotional wellbeing in addition to medical needs.We conducted a thorough literature search on PubMed,EMBASE,and Scopus using our tailored strategy,incorporating keywords such as critical care,telemedicine,and sepsis management.A total of 125 articles meeting our criteria were included for qualitative synthesis.To ensure reliability,we focused only on articles published in the English language within the last two decades,excluding animal studies,in vitro/molecular studies,and non-original data like editorials,letters,protocols,and conference abstracts.These advancements reflect a dynamic landscape in critical care medicine,where technology,research,and patient-centered approaches converge to improve the quality of care and save lives in ICUs.The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.

BILL Strategy:Points to Consider During the Performance and Interpretation of Critical Care Echocardiography

The growing utilization of critical care echocardiography(CCE) by clinicians necessitates a meticulous review of clinical conditions in critically ill patients, both before and during the examination. The reviewing process of clinical conditions minimizes the risk of overlooking or misinterpreting crucial findings. This article proposes a comprehensive strategy, namely BILL strategy, to integrate into the CCE protocol, where "B" represents baseline respiratory and hemodynamic support, "I" signifies information gleaned from invasive monitoring, including central venous pressure and thermodilution-derived cardiac output, the first "L" denotes laboratory results such as central venous oxygen saturation, troponin, and brain natriuretic peptide, and the second "L" refers to lung ultrasound data. Combining the BILL strategy with CCE can enhance comprehensive understanding of critical conditions, potentially leading to improved diagnostic accuracy and patient outcomes.

Acute pancreatitis in the critical care setting:A review of assessment and intervention strategies

The incidence of acute pancreatitis(AP),a condition characterized by inflammation in the pancreas,has been increasing globally and is associated with several complications.This review elaborated on the etiology,clinical presentation,severity assessment,and treatment modalities of AP,mainly in the critical care setting.Patients with severe AP,as indicated by organ failure(>48 hours from onset),warrant treatment in the intensive care unit setting.The most common etiologies,biliary disease and alcohol consumption,and the advanced diagnostic tools used for the identification of the cause are highlighted.Different severity assessment tools are utilized for grading the severity of the disease,predicting patient outcomes,determining the associated risk,and guiding treatment decisions.The treatment interventions comprise various approaches,such as anti-infective therapy enteral nutrition,analgesics for pain,or minimally invasive surgical procedures,thereby demonstrating an evolving landscape of AP management.Furthermore,various complications such as necrosis,organ failure,and hemorrhage,necessitate disease monitoring and differential diagnosis and are crucial for optimal management of patients.Novel treatment modalities and advancements in multidisciplinary care emphasize the potential for reducing the burden of AP in critical care settings.

Ten misconceptions regarding decision-making in critical care

Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system.Patient complexity,illness severity,and the urgency in initiating proper treatment all contribute to decision-making errors.Clinician-related factors such as fatigue,cognitive overload,and inexperience further interfere with effective decision-making.Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error.This evidence-based review discusses ten common misconceptions regarding critical care decision-making.By understanding how practitioners make clinical decisions and examining how errors occur,strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.

Reimagining critical care:Trends and shifts in 21st century medicine

primarily driven by advancements in technology,changes in healthcare delivery,and a deeper understanding of disease processes.Advancements in technology have revolutionized patient monitoring,diagnosis,and treatment in the critical care setting.From minimally invasive procedures to advances imaging techniques,clinicians now have access to a wide array of tools to assess and manage critically ill patients more effectively.In this editorial we comment on the review article published by Padte S et al wherein they concisely describe the latest developments in critical care medicine.

Artificial intelligence:Applications in critical care gastroenterology

Gastrointestinal(GI)complications frequently necessitate intensive care unit(ICU)admission.Additionally,critically ill patients also develop GI complications requiring further diagnostic and therapeutic interventions.However,these patients form a vulnerable group,who are at risk for developing side effects and complications.Every effort must be made to reduce invasiveness and ensure safety of interventions in ICU patients.Artificial intelligence(AI)is a rapidly evolving technology with several potential applications in healthcare settings.ICUs produce a large amount of data,which may be employed for creation of AI algorithms,and provide a lucrative opportunity for application of AI.However,the current role of AI in these patients remains limited due to lack of large-scale trials comparing the efficacy of AI with the accepted standards of care.

Impacts of fighting against COVID-19 on critical care nurses'psychological and physical health:a literature review

Objective:To provide insight into the effects of the coronavirus disease(COVID-19)pandemic on the physical and psychological health of critical care nurses in adult units.Methods:A systematic search through the CINAHL,MEDLINE,and EMbase databases were performed.Studies that addressed“critical care nurses,”“COVID-19,”“physical effect,”and“psychological effect”from different perspectives were reviewed.Results:A total of 42 ar ticles were reviewed based on 2 aspects:critical care nurses'psychological and physical health.Negative emotions were the most common conditions:fear,anxiety,depression,and post-traumatic stress disorder(PTSD).Burnout,falling ill and having thoughts of self-harm,fatigue,physical burden,sleeping disorders,and chronic work overload also adversely affected the nurses'health.The nurses'health deteriorated because of the changes in the unfamiliar working environment and processes,colossal workload and chronic exhaustion,worries about themselves and their families,social response,and witnessing the death toll.Conclusions:Critical care nurses experienced adverse effects of the institutional reaction,social response,and individuals'reply to the COVID-19 pandemic upon their psychological and physical health.Suppor ting services and preparation for other unprecedented situations should be sustainably available.

Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China

Thrombocytopenia is a common complication of critical care patients.The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia.Therefore,the Critical Care Medicine Committee of Chinese People’s Liberation Army(PLA)worked with Chinese Society of Laboratory Medicine,Chinese Medical Association to develop this consensus to provide guidance for clinical practice.The consensus includes five sections and 27 items:the definition of thrombocytopenia,etiology and pathophysiology,diagnosis and differential diagnosis,treatment and prevention.

Glucose control in critical care

Glycemic control among critically-ill patients has been a topic of considerable attention for the past 15 years. An initial focus on the potentially deleterious effects of hyperglycemia led to a series of investigations regarding intensive insulin therapy strategies that targeted tight glycemic control. As knowledge accumulated, the pursuit of tight glycemic control among critically-ill patients came to be seen as counterproductive, and moderate glycemic control came to dominate as the standard practice in intensive care units. In recent years, there has been increased focus on the importance of hypoglycemic episodes, glycemic variability, and premorbid diabetic status as factors that contribute to outcomes among critically-ill patients. This review provides a survey of key studies on glucose control in critical care, and aims to deliver perspective regarding glycemic management among critically-ill patients.

Heart failure in COVID-19 patients:Critical care experience

Patients with heart failure(HF)may be at a higher risk of coronavirus disease 2019(COVID-19)infection and may have a worse outcome due to their comorbid conditions and advanced age.In this narrative review,we aim to study the interaction between COVID-19 and HF from a critical care perspective.We performed a systematic search for studies that reported HF and critical carerelated outcomes in COVID-19 patients in the PubMed and Medline databases.From a total of 1050 papers,we identified 26 that satisfied the eligibility criteria for our review.Data such as patient demographics,HF,intensive care unit(ICU)admission,management,and outcome were extracted from these studies and analyzed.We reported outcomes in heart-transplant patients with COVID-19 separately.In hospitalized patients with COVID-19,the prevalence of HF varied between 4%and 21%.The requirement for ICU admission was between 8%and 33%.HF patients with COVID-19 had an overall mortality rate between 20%and 40%.We identified that HF is an independent predictor of mortality in hospitalized COVID-19 patients,and patients with HF were more likely to require ventilation,ICU admission and develop complications.Patients with HF with reduced ejection fraction did worse than those with HF with midrange ejection fraction,and HF with preserved ejection fraction.COVID-19 patients with HF should be identified early and managed aggressively in an attempt to improve outcomes in this cohort of patients.

Clinical Decision-Making among Critical Care Nurses: A Qualitative Study

The purposes of this study were to describe the decision making process and decision activities of critical care nurses in natural clinical settings. An exploratory descriptive approach utilizing both interview and observation methods, was used for data collection. The study involved twenty four critical care nurses from three hospitals in Jordan. Participant observation was performed to understand the routine clinical decisions made by Intensive Care nurses. About 150 hours of observations were spent in the involved Intensive Care Units. Nurses were interviewed to elicit information about how they made decisions about patient’s care. The study revealed that the most common model nurses tend to use was intuitive model in order to observe the cues relating to the patient’s situation. Data revealed that the decision making process is continuous and that experience is one of the main factors that determine nurses’ ability to take decisions. Five themes were generated from the data: on-going process, autonomy, experience/power, joint/ethical decisions, and advocacy. Critical care nurses were seen to be sensitive to the patient’s verbal and non-verbal cues;they were able to respond to these evidences to ensure that the patient’s condition did not deteriorate. Critical care nurses are likely to be more confident and effective when dealing with patient’s changing situations with more experience.

Predictive modeling in neurocritical care using causal artificial intelligence

Artificial intelligence(AI)and digital twin models of various systems have long been used in industry to test products quickly and efficiently.Use of digital twins in clinical medicine caught attention with the development of Archimedes,an AI model of diabetes,in 2003.More recently,AI models have been applied to the fields of cardiology,endocrinology,and undergraduate medical education.The use of digital twins and AI thus far has focused mainly on chronic disease management,their application in the field of critical care medicine remains much less explored.In neurocritical care,current AI technology focuses on interpreting electroencephalography,monitoring intracranial pressure,and prognosticating outcomes.AI models have been developed to interpret electroencephalograms by helping to annotate the tracings,detecting seizures,and identifying brain activation in unresponsive patients.In this mini-review we describe the challenges and opportunities in building an actionable AI model pertinent to neurocritical care that can be used to educate the newer generation of clinicians and augment clinical decision making.

Critical care practice in India:Results of the intensive care unit need assessment survey(ININ2018)

BACKGROUND A diverse country like India may have variable intensive care units(ICUs)practices at state and city levels.AIM To gain insight into clinical services and processes of care in ICUs in India,this would help plan for potential educational and quality improvement interventions.METHODS The Indian ICU needs assessment research group of diverse-skilled individuals was formed.A pan-India survey"Indian National ICU Needs"assessment(ININ 2018-I)was designed on google forms and deployed from July 23rd-August 25th,2018.The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories(UTs).In addition to emails and phone calls,social medial applications-WhatsApp™,Facebook™and LinkedIn™were used to remind and motivate providers.By completing and submitting the survey,providers gave their consent for research purposes.This study was deemed eligible for category-2 Institutional Review Board exempt status.RESULTS There were total 134 adult/adult-pediatrics ICU responses from 24(83%out of 29)states,and two(28%out of 7)UTs in 61 cities.They had median(IQR)16(10-25)beds and most,were mixed medical-surgical,111(83%),with 108(81%)being adult-only ICUs.Representative responders were young,median(IQR),38(32-44)years age and majority,n=108(81%)were males.The consultants were,n=101(75%).A total of 77(57%)reported to have 24 h in-house intensivist.A total of 68(51%)ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio.More than 80%of the ICUs were open,and mixed type.Protocols followed regularly by the ICUs included sepsis care,ventilator-associated pneumonia(83%each);nutrition(82%),deep vein thrombosis prophylaxis(87%),stress ulcer prophylaxis(88%)and glycemic control(92%).Digital infrastructure was found to be poor,with only 46%of the ICUs reporting high-speed internet availability.CONCLUSION In this large,national,semi-structured,need-assessment survey,the need for improved manpower including;in-house intensivists,and decreasing patient-tonurse ratios was evident.Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized.Additionally,subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Characteristic Duties of Critical Care Nurses in Japan: A Time-Study Comparison with Neurology Ward Nurses

Background: The importance of the acute phase in hospitals has been increasing. While administering high-level critical care, the working styles of critical care nurses, the types of clinical care they provide, and the way in which they prioritize tasks, remain unclear. Aim of this study was to elucidate the characteristic duties of critical care nurses through a comparison with neurological ward nurses. Methods: We recorded the duties of critical care nurses and neurology ward nurses (10 each) using a time-study design. Duties were measured separately by action, classified using a classification table, and differences between the two groups were compared. Results: No differences in the number of actions were observed between the two groups. The top five items that required the most time for critical care nurses were, “Movement”, “Administration and oxygen management”, “Handover process/Doctor’s rounds”, “Preparation for entry and exit management of patients”, and “Bed bathing (for bedbound patients)”. Of the 195 items, significant differences between the groups were noted for 34 items, while the duties of critical care nurses were best characterized by bed bathing (for bedbound patients), changing position, confirmation of infusion tubes, handover process/doctor’s rounds, and preparation for entry and exit management of patients. Conclusion: A characteristic of critical care nurses is that they must remain near patients and perform tasks while moving only a short distance. Moreover, the promotion of tasks while communicating with physicians is presumed to play a role in the promotion of team medicine. Furthermore, much time was spent caring for patients in bed, and a lot of time was devoted to the preparation and finalizing of treatments and care, suggesting the possibility that more time can be spent on caring for patients through a revision of duties.

Who decides in withdrawal of treatment in a critical care setting? A case study on ethical dilemma

Case description:Withdrawal of treatment is a common practice in critical care settings,perticularly when treatment is considered futile.The case study demonstrates an ethical dilemma,in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes.Under such a circumstance,withdrawal of treatment will inevitably be considered,although his family refused to do so.Consequently,acritical question must be answered:Who should make the decision?Ethical dilemma identification:Danny decided to withdraw the use of life-support,whilst his wife and adult children refused to do so.The ethical dilemma is illustrated by the following question:Who decides the withdrawal of treatment in a critical care setting?Analysis:To provide an opotional solution to this case and make the best moral decision,the current study will critically discuss this issue in conjunction with ethical principles,philosophical theories and the values statement of the European and Chinese nurses'codes of ethics.Additionally,the associated literature relative to this case are analysed before the decision-making.Ethical decision-making:The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment.If his family is involved in the discussion,the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.Results:In Danny's case,health professionals opted to respect his decision to withdraw treatment.The medical staff maintained an effective communication with the family involved,and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.

Sensorineural hearing dysfunction after discharge from critical care in adults:A retrospective observational study

Background Patients undergoing intensive care are exposed to risk factors for hearing impairment.This study assessed the worse changes in pure tone average(PTA)thresholds after intensive care and identified the factors associated with worse hearing function.Methods We conducted a single-centre retrospective study,and included adult patients admitted to the intensive care unit(ICU)of Kurashiki Central Hospital between January 2014 and September 2019,who had regular pure tone audiometry performed before and after ICU admission.Correlations between changes in PTA threshold and patient characteristics,were evaluated.The included ears were classified as those with worse hearing(>10 dB increase in the PTA threshold)and those without worse hearing,and the baseline characteristics were compared.Results During the study period,125 ears of 71 patients(male:female ratio,35:36;mean age,72.5±12.3 years)met the eligibility criteria.Age,sex,and the use of furosemide were not correlated with changes in PTA threshold.Univariate analysis showed that ears with worse hearing were associated with a lower serum platelet count than ears without worse hearing(153±85×10^(9)/L vs.206±85×10^(9)/L,respectively;P=0.010),and the rate of planned ICU admission(elective surgery)was higher in the worse hearing group(57.1% vs.28.8%,respectively;p=0.011).Conclusions Age,sex,and the use of furosemide did not have adversely affect hearing function.Low serum platelet count and planned admission appear to be risk factors for worse hearing.

Mortality of critical care interventions in the COVID-19:A systematic review

BACKGROUND The novel coronavirus severe acute respiratory syndrome coronavirus 2 is associated with a severe disease known as coronavirus disease 2019(COVID-19).A small percentage of patients with COVID-19 will require intensive care and possibly mechanical ventilation.The mortality of intensive care interventions in patients with COVID-19 remains unclear.AIM To identify mortality rate of COVID-19 patients receiving different interventions in the critical care unit.METHODS We searched OVID Medline,SCOPUS,MedRxIv,preprints.org,and Centers for Disease Control databases from November 2019 to April 10,2020 for articles on COVID-19.Teams of 2 independent reviewers reviewed titles and abstract for studies that reported mortality of human adults with COVID-19 and exposure to a critical care intervention[Intensive care admission,mechanical ventilation,acute hemodialysis,extracorporeal membrane oxygenation,or cardiopulmonary resuscitation(CPR)].We used a descriptive analysis and unweighted averages of mortality across studies.RESULTS Our search identified 6973 articles and 20 met inclusion:17 for intensive care,13 for mechanical ventilation,5 for hemodialysis,2 for extracorporeal membrane oxygenation,and 1 for CPR.Mortality associated with intensive care admission ranged from 9%-83%,with overall mortality 32.5%(95%CI:32.4%-32.6%).Mortality associated with intubation from 16.7%-100%with overall mortality 64.0%(95%CI:62.4%-65.5%).In patients requiring hemodialysis,mortality ranged from 0%-100%,with average mortality 75.3%(95%CI:72.6%-77.4%).CONCLUSION Patients with COVID-19 requiring intensive care have high mortality rates.Authorities can use this data to establish pharmacoeconomic studies to make decisions about allocation of scarce resources if necessary.

Relationship between clinical performance and professional self-concept in critical care nurses

Objective:To determine the relationship between clinical performance and professional self-concept in critical care nurses.Methods:This study was conducted on 308 critical care nurses.Data gathering instruments were nurses’clinical performance questionnaire(NCPQ)and nursing professional self-concept measure(NPSCM).Independent sample t-test,one-way analysis of variance(ANOVA),and Pearson correlation coefficient were used for data analyses.Results:The average age of the nurses was 33.74±7.01 years.The clinical performance score of female nurses was significantly higher than male nurses.In the domain of clinical performance,clinical judgment and clinical inquiry had the highest and lowest scores,respectively.In the nurses’professional self-concept,the highest and lowest scores were awarded to the subscales of self-confidence and staff relations,respectively.In addition,there was a significant positive correlation between self-concept and clinical performance of nurses.Conclusions:Increasing professional self-concept improves the clinical performance of critical care nurses.Professional self-concept enhancement measures are recommended to improve the clinical performance of nurses in critical care units.

Prevalence, Species Distribution and Antifungal Susceptibility Profile of <i>Candida</i>Species Isolated from Bloodstream of Critical Care Unit Patients in a Tertiary Care Hospital in Kenya

The upsurge of candidemia in the past years has been an immense encumbrance on public health and the number of deaths caused by candidemia particularly in critical care unit patients is devastating. Candida species harbor a 30% - 60% mortality rate and compared to stable people or those with less serious illnesses, this ranges from 60% to 80% of those who are chronically ill patients. Grounded on a recent report from a tertiary care hospital in Kenya showing the emergence of previously unobserved species: Candida auris, this study aimed to determine the prevalence, species distribution, and antifungal susceptibility profile of candidemia in critical care unit patients of the hospital. 378 Critical Care Unit patients were enrolled for the study from January 2019 to January 2020. Positive archived isolates were sub-cultured using Saboraud Dextrose Agar. Candida species were identified utilizing API20C AUX and Vitek-2. Antifungal susceptibility testing was conducted using the Liofilchem MIC Test strip. Out of 378 patients, thirty-one presented a positive culture for Candida species. The prevalence of Candidemia was 8.2% with 9 (29.03%) Candida auris, 8 (25.81%) Candida albicans, 6 (19.35%) Candida parapsilosis, 3 (9.68%) Candida famata, 3 (9.68%) Candida tropicalis, 1 (3.23%) Candida duobushaemolumonii, and 1 (3.23%) Candida lusitaniae. A resistance pattern to Fluconazole was observed among Candida auris and Candida parapsilosis, and resistance to Flucytosine was observed in Candida tropicalis, whereas susceptible MIC values were obtained for the other drugs. There is an increase in candidemia among critical care unit patients in the health facility posing a public health challenge. Moreover, the onset of new species Candida auris which is unprecedented in Kenya warrants enhanced infection control, and the uniform resistance of Candida auris, Candida parapsilosis, and Candida tropicalis towards Fluconazole and Flucytosine necessitate constant drug monitoring for empirical treatment regime. In contrast, the high potency of Echinocandins and Amphotericin-B demonstrate them as the drug of choice.