Prognostication in Neurocritical Care.

OBJECTIVE: This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication. LATEST DEVELOPMENTS: Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care. ESSENTIAL POINTS: This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.

The Role of Intermediate Care in Supporting Critically Ill Patients and Critical Care Infrastructure.

Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.

Patient-management problem in the evaluation of intensive medicine.

INTRODUCTION: In intensive care medicine (ICM), the use of Patient-Management Problem (PMP) remains limited and no feedback from students is available. AIM: To compare the feasibility of employing PMP referring to clinical cases (CC) as assessment tools for appraising the knowledge and competencies in ICM students; and to gather the students' perception regarding this experience. METHODS: it was a cross-sectional randomized trial. Were included, external students in the 3rd year of the 2nd cycle of medical studies (3rd-SCMS) during their ICM externship. All the participants underwent two random draws (the 1st one for assessment tool to be started (PMP or CC) and the 2nd for the passage order for PMP. Two PMPs versus two grouped QCMs-CC were prepared and a satisfaction questionnaire was distributed. The main judgment criterion was the effect of each assessment tool on the students' decision-making process. This focused on the relevance of the elements provided by each technique, the implication and the difficulty felt. The secondary endpoint was the scores taken for each tool tested. RESULTS: 20 students were included. All participants had previous experience with PMPs and only nine were familiar with grouped MCQs-CC. PMP scores were 14.9 for the 1st theme and 15.8 for the 2nd theme. The median of the grouped MCQs-CC scores was 14 [12-16] for both. The scores didn't differ between the two techniques. For the 1st theme: the scores were negatively correlated (r=-0.58 and p=0.007). Students felt a better satisfaction for PMP evaluation (p<10-3), the elements provided by PMP were more relevant for decision-making process (p<10-3), the involvement was more felt with PMP (p<10-3) and difficulty was more felt with CCs (p<10-3). The effect of PMP was found to be significant on clinical reasoning (n=36), self-assessment (n=38), problem solving (n=40) and decision making (n=39). Students recommended strongly PMP as a tool of evaluation in ICM (p<10-3). CONCLUSION: scores were comparable between the two tested techniques. The positive perception of students regarding PMP encourages its generalization and teacher training must be strengthened.

The reliability of the College of Intensive Care Medicine of Australia and New Zealand "Hot Case" examination.

BACKGROUND: High stakes examinations used to credential trainees for independent specialist practice should be evaluated periodically to ensure defensible decisions are made. This study aims to quantify the College of Intensive Care Medicine of Australia and New Zealand (CICM) Hot Case reliability coefficient and evaluate contributions to variance from candidates, cases and examiners. METHODS: This retrospective, de-identified analysis of CICM examination data used descriptive statistics and generalisability theory to evaluate the reliability of the Hot Case examination component. Decision studies were used to project generalisability coefficients for alternate examination designs. RESULTS: Examination results from 2019 to 2022 included 592 Hot Cases, totalling 1184 individual examiner scores. The mean examiner Hot Case score was 5.17 (standard deviation 1.65). The correlation between candidates' two Hot Case scores was low (0.30). The overall reliability coefficient for the Hot Case component consisting of two cases observed by two separate pairs of examiners was 0.42. Sources of variance included candidate proficiency (25%), case difficulty and case specificity (63.4%), examiner stringency (3.5%) and other error (8.2%). To achieve a reliability coefficient of > 0.8 a candidate would need to perform 11 Hot Cases observed by two examiners. CONCLUSION: The reliability coefficient for the Hot Case component of the CICM second part examination is below the generally accepted value for a high stakes examination. Modifications to case selection and introduction of a clear scoring rubric to mitigate the effects of variation in case difficulty may be helpful. Increasing the number of cases and overall assessment time appears to be the best way to increase the overall reliability. Further research is required to assess the combined reliability of the Hot Case and viva components.

Where the Postanesthesia Care Unit and Intensive Care Unit Meet.

The intensive care unit (ICU) was born from the postanesthesia care unit (PACU). In today's hospital systems, there remains a lot of overlap in the care missions of each location. The patient populations share many similarities and many of the same care, technology, and care protocols apply to patients in both units. As shown by the COVID-19 pandemic, there is immense value in maintaining protocols, processes, and staffing models for the safe care of ICU patients in the PACU when ICU demands exceed capacity.

Critical Care in the Austere Environment.

Practice of critical care in austere settings involves navigating rapidly evolving environments, where physical resources, provider availability, and healthcare capacity are constrained. Austere Critical Care focuses on maintaining the highest standard of care possible for patients while also identifying resource limitations, responding to patient surges, and adhering to proper triage practices at the austere site. This includes transferring the patient when able and necessary. This article describes the current practice of critical care medicine in the austere environment, using recent natural disasters, pandemics, and conflicts as case studies.

Early Warning Systems for Critical Illness Outside the Intensive Care Unit.

Early warning systems (EWSs) are designed and deployed to create a rapid assessment and response for patients with clinical deterioration outside the intensive care unit (ICU). These models incorporate patient-level data such as vital signs and laboratory values to detect or prevent adverse clinical events, such as vital signs and laboratories to allow detection and prevention of adverse clinical events such as cardiac arrest, intensive care transfer, or sepsis. The applicability, development, clinical utility, and general perception of EWS in clinical practice vary widely. Here, we review the field as it has grown from early vital sign-based scoring systems to contemporary multidimensional algorithms and predictive technologies for clinical decompensation outside the ICU.

Critical Care Delivery in the Emergency Department: Bringing the Intensive Care Unit to the Patient.

Boarding of critically ill patients in the Emergency Department (ED) has increased over the past 20 years, leading hospital systems to explore ED-focused models of critical care delivery. ED-critical care delivery models vary between health systems due to differences in hospital resources and the needs of the critically ill patients boarding in the ED. Three published systems include an ED critical care intensivist consultation model, a hybrid model, and an ED-intensive care unit model. Paraphrasing the Greek philosopher, Plato, "necessity is the mother of invention." This proverb rings true as EDs are facing an increasing challenge of caring for boarding patients, especially those who are critically ill.

Tele-Critical Care Support Outside the Intensive Care Unit.

Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.

Critical Illness Outside the Intensive Care Unit: Research Challenges in Emergency and Prehospital Settings.

Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for immediate treatment and the inability of patients to provide informed consent. Attempts to obtain consent from surrogate decision-makers can be intrusive and lead to unacceptable delays to treatment. These problems may be overcome by pragmatic approaches to study design and the use of supervised waivers of consent, which is ethical and appropriate in situations where there is high risk of poor outcome and a paucity of proven effective treatment.

Increasing the Volume of Delivered Enteral Feeds Using a Volume-Based Feeding Protocol in a Neuroscience Intensive Care Unit.

BACKGROUND: Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings. LOCAL PROBLEM: This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed. METHODS: This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project. RESULTS: During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients. CONCLUSIONS: Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

Composite outcome measures in high-impact critical care randomised controlled trials: a systematic review.

BACKGROUND: The use of composite outcome measures (COM) in clinical trials is increasing. Whilst their use is associated with benefits, several limitations have been highlighted and there is limited literature exploring their use within critical care. The primary aim of this study was to evaluate the use of COM in high-impact critical care trials, and compare study parameters (including sample size, statistical significance, and consistency of effect estimates) in trials using composite versus non-composite outcomes. METHODS: A systematic review of 16 high-impact journals was conducted. Randomised controlled trials published between 2012 and 2022 reporting a patient important outcome and involving critical care patients, were included. RESULTS: 8271 trials were screened, and 194 included. 39.1% of all trials used a COM and this increased over time. Of those using a COM, only 52.6% explicitly described the outcome as composite. The median number of components was 2 (IQR 2-3). Trials using a COM recruited fewer participants (409 (198.8-851.5) vs 584 (300-1566, p = 0.004), and their use was not associated with increased rates of statistical significance (19.7% vs 17.8%, p = 0.380). Predicted effect sizes were overestimated in all but 6 trials. For studies using a COM the effect estimates were consistent across all components in 43.4% of trials. 93% of COM included components that were not patient important. CONCLUSIONS: COM are increasingly used in critical care trials; however effect estimates are frequently inconsistent across COM components confounding outcome interpretations. The use of COM was associated with smaller sample sizes, and no increased likelihood of statistically significant results. Many of the limitations inherent to the use of COM are relevant to critical care research.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. / Präoperative Evaluation erwachsener Patientinnen und Patienten vor elektiven, nicht herz-thoraxchirurgischen Eingriffen : Eine gemeinsame Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, der Deutschen Gesellschaft für Chirurgie und der Deutschen Gesellschaft für Innere Medizin.

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.