Intensive care medicine essentials [CICM]: Overview

The “ICU Toolbox” collection provides practical advice on a range of special focus topics. It aims to be a beacon of practical insights, offering concise and insightful hands-on guidance for healthcare professionals navigating the intricate landscapes of intensive care, and providing them with tangible tools and strategies to enhance their daily practice.

Abstract
Digital health refers to the field of using and developing technology to improve health outcomes. Digital health and digital health interventions (DHIs) within the area of intensive care and critical illness survivorship are rapidly evolving. Digital health interventions refer to technologies in clinical interventional format. A DHI could support clinicians with increasing clinical demands to have improved oversight of their patients' recovery trajectory or potential for deterioration, improve efficiency of healthcare delivery, and/or predict patient outcomes. In this narrative review, DHIs are explored across the continuum from in the ICU (recognising and managing clinical deterioration, identifying individuals at risk of poor recovery outcomes, tailoring care of the ICU patient and supporting the emotional needs of their family) through to integration in the primary care setting (adjuncts to ICU follow-up clinics and tracking, coaching and remote monitoring). Some of the DHIs discussed in this narrative review (to name a few) include interventions delivered via: Telehealth, artificial intelligence, wearable devices, virtual reality, and mobile phone applications (apps). Additionally, exploration of DHIs used successfully in other health fields are discussed to highlight potential opportunities for adaptation to the ICU context. Finally, the review provides an overview of considerations needed in the development of new DHIs. Development should consider the intended user, barriers to technology engagement and design. In the implementation of a new DHI, the World Health Organization (WHO) Global Strategy on Digital Health and appropriate evaluation should be considered prior to scaling up. Optimal implementation of DHIs could help address the key challenges of the ICU field.

Abstract
Objective: To evaluate characteristics and outcomes in critically ill patients with Guillain-Barré syndrome (GBS).

Methods: Consecutive adults with GBS who required intensive care unit (ICU) admission at a tertiary-care hospital between 1999 and 2020 were enrolled into this retrospective cohort study. Demographics, clinical data and patient outcomes were compared between patients who did or did not receive mechanical ventilation (MV).

Results: During the study period, the number of ICU admissions gradually rose from approximately 900 to 3000 annually. Forty-three patients had GBS and were included, of whom, 27 (62.8%) received MV for a median of 13 days. The MV group stayed longer in the ICU (median, 26 versus 6 days) and in the hospital (median, 120 versus 39 days) than the non-MV group. Most patients in the MV group (22 [81.5%]) required tracheostomy. At maximum follow-up, Hughes Functional Grading scores were 0 (full recovery) in 11 patients (25.5%), 1-3 in 18 (41.8%), 4-5 in 12 (27.9%), and 6 (death) in two (4.6%, both in the MV group), with higher median Hughes score in the MV group (3 versus 0.5). Complications during ICU and hospital stay included: veinous thromboembolism in five (11.6%), gastrointestinal bleeding in three (7.0%), bacteremia in five (11.6%), bedsore in one (2.3%), and GBS-treatment side effects in four (9.4%) patients; all of these complications occurred within the MV group.

Conclusions: GBS was an uncommon reason for ICU admission. The findings highlight significant morbidity with GBS, particularly among patients who need MV.

Abstract
Background: Septic shock is common and associated with significant morbidity and mortality. The ADRENAL trial examined the use of hydrocortisone in patients with septic shock, demonstrating no difference in patient-centred outcomes but a decrease in the time to shock resolution. The change in clinical practice related to the publication of the ADRENAL trial is currently unknown.

Methods: A retrospective cohort study examining the use of hydrocortisone in patients with septic shock was conducted in 12 intensive care units (ICUs). A segmented linear regression was performed to identify a stepwise change in hydrocortisone administration and 90-day mortality associated with the publication of the ADRENAL trial.

Results: We included 4,198 patients with a mean age of 58 years (standard deviation, SD17), and the median noradrenaline equivalent score (NEE) was 0.07 µg/kg/min (IQR 0.02 - 0.17). Segmented regression analysis for hydrocortisone administration identified two breakpoints, 3 months before and 6 months after publication, leading to three periods: Pre-publication, Transition and Post-publication. Compared to the pre-publication period, the Transition and Post-publication cohorts had a higher proportion of hydrocortisone administration (28% vs. 34% vs. 43%; p < 0.0001). Furthermore, after adjustment for temporal change, the transition period had a significant change in the slope of the proportion of patients receiving hydrocortisone (-0.1% per month vs. +1.4% per month; p = 0.026), whereas this was not statistically significant during the post-publication period (+0.1% per month, p = 0.66). After adjusting for confounders, the Transition and Post-publication periods were independently associated with an increase in hydrocortisone (OR 1.4, 95% CI 1.14 - 1.77; p = 0.0015 and OR 2.03; 95% CI 1.74 - 2.36; p < 0.001, respectively). Furthermore, after adjusting for confounders, when compared to the Pre-transition period, the use of hydrocortisone was associated with a statistically significant decrease in 90-day mortality (14% vs. 24% absolute difference, aHR for hydrocortisone effect -0.81; 95% CI 0.65 - 0.99; p = 0.044).

Conclusion: Publication of the ADRENAL trial changed clinical practice in Queensland ICUs with increased prescription of hydrocortisone for patients with septic shock with an associated reduction in mortality.

Keywords: septic shock hydrocortisone ADRENAL trial critical care.