Global collaboration is the cornerstone of scientific advancement. Frontiers in Medicine has organized a series of special edition Research Topics, with the goal of highlighting the latest advancements in Intensive Care Medicine and Anesthesiology across the globe, showcasing the academic excellence and high-quality work of internationally recognized researchers. These collections aim to shed light on the recent progress made across the entire breadth of the field, and reflect on the future challenges faced by researchers across borders.

WellSpan Health

Views

Article Views

Article Downloads

Frontiers in Medicine

Intensive Care Medicine and Anesthesiology

Global Excellence in Intensive Care Medicine and Anesthesiology: North America

We enthusiastically present the special edition research series in Frontiers in Medicine, &#x201c;Global Excellence in Intensive care medicine and anesthesiology: North America&#x201d;. This series aims to highlight the global collaborations in intensive care medicine that form the cornerstone of scientific development. The history of intensive care medicine has been rife with turbulent times, the most recent being the COVID-19 pandemic. Hospitals and health systems around the globe adapted to the increasing demand for healthcare need. This has undoubtedly placed an unimaginable strain on healthcare workers but has also fostered an environment for innovation. Out-of-the-box thinking and innovation in critical care medicine are the mainstay themes in this series.<a href="https://doi.org/10.3389/fmed.2021.773461">Song et al.</a> present an analysis of the first multicenter registry of CytoSorb use (a blood purification method) in COVID-19 patients on ECMO. The FDA gave CytoSorb emergency use authorization (EUA) for the indication to hemoadsorb inflammatory cytokines in patients with COVID-19 in respiratory failure (<a href="#B1">1</a>, <a href="#B2">2</a>). The ICU mortality was 30.8% by 153 days among 52 studied patients. The rates of ICU discharge exceeded mortality after starting therapy. <a href="https://doi.org/10.3389/fmed.2021.773461">Song et al.</a> conclude that CytoSorb therapy shows a potential therapeutic benefit in specific subsets of COVID-19 patients.Complementing the latest therapies to treat severe COVID-19, intensive care units worldwide also necessitated tools for improved communication (<a href="#B3">3</a>). The use of telehealth expanded during this time. <a href="https://doi.org/10.3389/fmed.2022.883126">Laudanski et al.</a> studied the perceptions and communications of remote teams in Tele-critical care medicine (tele-CCM) across 16 intensive care units. These teams consisted of a multi-professional group of medical doctors (eMD), registered nurses (eRN), and respiratory therapists (eRT). Through their comprehensive study, <a href="https://doi.org/10.3389/fmed.2022.883126">Laudanski et al.</a> inspected close to 40,000 engagements that occurred using tele-CCM services, analyzed communication patterns, and compared variations between members of the healthcare teams. Their analyses will help guide policy making when planning for the resources required to maintain the Tele-CCM service.Critical care and anesthesiology practices are not limited to the operating room or intensive care unit only. The pre-operative and post-operative settings, as well as the post-critical care illness journeys, are just as essential. The following two articles delve into these domains.Undergoing surgery is undoubtedly a stressful time for patients. The sympathetic nervous system's adrenergic response is augmented. Pain and stress are some of the most common disstressors. Often, pharmacological therapies are utilized in the peri-operative period to blunt these responses. While they are useful, non-pharmacologic interventions are often overlooked. <a href="https://doi.org/10.3389/fmed.2022.821022">Ginsberg et al.</a> review the use of perioperative music medicine (PMM) to reduce pain and stress around surgery. They also look into the effects of PMM on heart rate variability (HRV) as a marker of surgery-induced sympathetic stress response. Perioperative music medicine is a promising addition to surgical practices, with low barriers to adoption and a wide range of patient benefits.The hospital discharge papers do not mean the end of a patient's journey with a critical illness. <a href="https://doi.org/10.3389/fmed.2022.821022">Ahmed et al.</a> set out to explore patient-centered outcomes in electronic medical records following critical illness in the elderly population. This pilot study showed that “free text” in the EHR contains essential data that give insight into patients' lives after recovering from critical illness. They show that the majority of the studied charts (86%) had enough information to paint a picture of the patient's health state pre and post-ICU admission. These promising findings will pave the path to conducting larger-scale studies to define important patient-centered outcomes and establish ways to extract them from EMR (<a href="#B4">4</a>, <a href="#B5">5</a>). The goal is for these outcomes to be used in critical care research to complement traditional outcomes like mortality rates. Data mining presents a functional tool to use in this endeavor (<a href="#B6">6</a>).In summary, the research series &#x201c;Global excellence in intensive care medicine and anesthesiology: North America&#x201d; reflects on relevant contemporary questions and seeks innovative solutions to improve patient outcomes. Future volumes of the series will continue to highlight topics of interest in critical care and anesthesiology communities.ME conceived the idea and drafted the manuscript. RK conceived the idea, critically reviewed the paper, and interpretation of the work. Both authors contributed to the article and approved the final submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Global excellence in intensive care medicine and anesthesiology: North America

Background: Our study addresses the gap in characterization of engagements by the remote tele-CCM team with the bedside team. Methods: REDCap self-reported activity log collected engagement duration, triggers (emergency button, tele-CCM software platform, autonomous algorithm, asymmetrical communication platform, phone), expediency, nature (proactive rounding, predetermined task, response to medical needs), communication modes, and acceptance. Seven hospitals with 16 ICUs were overseen between 9/2020 and 9/2021 by team consisting of attending (eMD), nurses (eRN), and respiratory therapists (eRT). Results: 39,915 engagements were registered. eMD had a significantly higher percentage of emergent and urgent engagements (31.9%) versus eRN (9.8%) or eRT (98.2%). The average tele-CCM intervention took 16.1±10.39 minutes for eMD, 18.1±16.23 for eRN, and 8.2±4.98 minutes for eRT with significant variation between engagement types, expediency, hospitals and ICUs types. During the observation period, there was a shift in intervention triggers with the increase in autonomous algorithmic ARDS detection concomitant with predominant utilization of asynchronous communication, phone engagements and the tele-CCM module of EPIC at the expense of the share of proactive rounding. eRT communicated more frequently with bedside staff (%MD=37.8%; %RN=36.8, %RT=49.0% (χ2[2, N=20,223] =1,574.56; p<0.00001) but mostly with eRT. In contrast, the eMD communicated with all ICU stakeholders while the eRN mostly communicated chiefly with the RN and house staff at the bedside. The rate of distress reported by tele-CCM staff was 2% among all interactions, with the entity hospital being the dominant factor. Conclusions: Delivery of tele-CCM services has to be tailored to the needs of the specific beneficiary of tele-CCM services.

Background: Our study addresses the gaps in knowledge of the characterizations of operations by remote tele-critical care medicine (tele-CCM) service providers interacting with the bedside team. The duration of engagements, the evolution of the tele-CCM service over time, and the distress during interactions with the bedside team have not been characterized systematically. These characteristics are critical for planning the deployment of teleICU services and preventing burnout among remote teleICU providers.Methods: REDCap self-reported activity logs collected engagement duration, triggers (emergency button, tele-CCM software platform, autonomous algorithm, asymmetrical communication platform, phone), expediency, nature (proactive rounding, predetermined task, response to medical needs), communication modes, and acceptance. Seven hospitals with 16 ICUs were overseen between 9/2020 and 9/2021 by teams consisting of telemedicine medical doctors (eMD), telemedicine registered nurses (eRN), and telemedicine respiratory therapists (eRT).Results: 39,915 total engagements were registered. eMDs had a significantly higher percentage of emergent and urgent engagements (31.9%) vs. eRN (9.8%) or eRT (1.7%). The average tele-CCM intervention took 16.1 ± 10.39 min for eMD, 18.1 ± 16.23 for eRN, and 8.2 ± 4.98 min for eRT, significantly varied between engagement, and expediency, hospitals, and ICUs types. During the observation period, there was a shift in intervention triggers with an increase in autonomous algorithmic ARDS detection concomitant with predominant utilization of asynchronous communication, phone engagements, and the tele-CCM module of electronic medical records at the expense of the share of proactive rounding. eRT communicated more frequently with bedside staff (% MD = 37.8%; % RN = 36.8, % RT = 49.0%) but mostly with other eRTs. In contrast, the eMD communicated with all ICU stakeholders while the eRN communicated chiefly with other RN and house staff at the patient's bedside. The rate of distress reported by tele-CCM staff was 2% among all interactions, with the entity hospital being the dominant factor.Conclusions: Delivery of tele-CCM services has to be tailored to the specific beneficiary of tele-CCM services to optimize care delivery and minimize distress. In addition, the duration of the average intervention must be considered while creating an efficient workflow.

Operation analysis of the tele-critical care service demonstrates value delivery, service adaptation over time, and distress among tele-providers

Background: Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside research setting. Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR. Methods: Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen’s kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively, if patient’s condition is ‘better’, ‘unchanged’ or ‘worse’. Days alive and out of hospital/health care facility, was a secondary outcome. Results: Thirty six of the 41 randomly selected patients (88%) survived critical illness. In majority of survivors (86%) EHR contained sufficient information to determine the difference in health status before and after critical illness.  Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up.  Conclusion: We demonstrated feasibility and reliability of assessing trajectory of changes in functional status, cognition, and selected mental health outcomes, from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes can be used alongside survival in quality improvement studies and pragmatic clinical trials.

Background: Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside the research setting. The Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR.Methods: Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen's kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively whether a patient's condition was “better,” “unchanged” or “worse.” Days alive and out of hospital/health care facility was a secondary outcome.Results: Thirty six of the 41 randomly selected patients (88%) survived critical illness. EHR contained sufficient information to determine the difference in health status before and after critical illness in most survivors (86%). Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up.Conclusion: We demonstrated the feasibility and reliability of assessing the trajectory of changes in functional status, cognition, and selected mental health outcomes from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes could be used alongside survival in quality improvement studies and pragmatic clinical trials.

Feasibility of Extracting Meaningful Patient Centered Outcomes From the Electronic Health Record Following Critical Illness in the Elderly

Clinical-experimental considerations and an approach to understanding the autonomic basis of improved surgical outcomes using Perioperative Music Medicine (PMM) are reviewed. Combined surgical, psycho-physiological, and experimental perspectives on Music Medicine (MM) and its relationship to autonomic nervous system (ANS) function are discussed. Considerations are given to the inter-related perioperative effects of MM, ANS and pain, and underlying vagal and other neural circuits involved in emotion regulation and dysregulation.  Many surgical procedures are associated with significant pain, which is routinely treated with post-operative opioid medications and which bring an additional set of detrimental side effects and delay recovery. Surgical trauma shifts the sympathetic autonomic nervous system to a sustained activation impairing physiological homeostasis and causing psychological stress, as well as metabolic and immune dysfunction that contribute to postoperative mortality and morbidity.  In this article we propose a plan to operationalize the study of mechanisms mediating the effects of MM in perioperative settings of orthopedic surgery (total knee replacement).  Using a parallel experimental rodent model of orthopedic surgery, we also propose to test the neuronal networks that we hypothesize mediate music modulation of peripheral- and psycho-physiology feedback control of homeostasis and affect emotion regulation.

Clinical-experimental considerations and an approach to understanding the autonomic basis of improved surgical outcomes using Perioperative Music Medicine (PMM) are reviewed. Combined surgical, psycho-physiological, and experimental perspectives on Music Medicine (MM) and its relationship to autonomic nervous system (ANS) function are discussed. Considerations are given to the inter-related perioperative effects of MM on ANS, pain, and underlying vagal and other neural circuits involved in emotional regulation and dysregulation. Many surgical procedures are associated with significant pain, which is routinely treated with post-operative opioid medications, which cause detrimental side effects and delay recovery. Surgical trauma shifts the sympathetic ANS to a sustained activation impairing physiological homeostasis and causing psychological stress, as well as metabolic and immune dysfunction that contribute to postoperative mortality and morbidity. In this article, we propose a plan to operationalize the study of mechanisms mediating the effects of MM in perioperative settings of orthopedic surgery. These studies will be critical for the implementation of PMM as a routine clinical practice and to determine the potential limitations of MM in specific cohorts of patients and how to improve the treatment.

Review of Perioperative Music Medicine: Mechanisms of Pain and Stress Reduction Around Surgery

Introduction:  CytoSorb extracorporeal blood purification therapy received FDA Emergency Use Authorization (EUA) to suppress hyperinflammation in critically ill COVID-19 patients.  The multicenter CTC Registry was established to systematically collect patient-level data, outcomes, and utilization patterns of CytoSorb under the EUA.        Methods:  Patient-level data was entered retrospectively at participating centers.  The primary outcome of the registry was ICU mortality.  Patient disposition of death, continuing ICU care, or ICU discharge was analyzed up to Day 90 after start of CytoSorb therapy.  Demographics, comorbidities, COVID-19 medications, inflammatory biomarkers, and details on CytoSorb use were compared between survivors and non-survivors in the veno-venous extracorporeal membrane oxygenation (ECMO) cohort.         Results:  Between April 2020 and April 2021, 52 patients received veno-venous ECMO plus CytoSorb therapy at 5 U.S. centers.     ICU mortality was 17.3% (9/52) on day 30, 26.9% (14/52) on day 90, and 30.8% (16/52) at final follow-up of 153 days.  Survivors had a trend toward lower baseline D-Dimer levels (2.3 ± 2.5 µg/mL vs. 19.8 ± 32.2 µg/mL, p=0.056) compared to non-survivors.  A logistic regression analysis suggested a borderline association between baseline D-Dimer levels and mortality with a 32% increase in the risk of death per 1 µg/mL increase (p=0.055).  CytoSorb was well tolerated without any device-related adverse events reported.     Conclusions:  CytoSorb therapy for critically ill COVID-19 patients on ECMO was associated with high survival rates suggesting potential therapeutic benefit.  Elevated baseline D-Dimer levels may suggest increased risk of mortality.   Prospective controlled studies are warranted to substantiate these results.

Introduction: CytoSorb extracorporeal blood purification therapy received FDA Emergency Use Authorization (EUA) to suppress hyperinflammation in critically ill COVID-19 patients. The multicenter CTC Registry was established to systematically collect patient-level data, outcomes, and utilization patterns of CytoSorb under the EUA.Methods: Patient-level data was entered retrospectively at participating centers. The primary outcome of the registry was ICU mortality. Patient disposition of death, continuing ICU care, or ICU discharge was analyzed up to Day 90 after start of CytoSorb therapy. Demographics, comorbidities, COVID-19 medications, inflammatory biomarkers, and details on CytoSorb use were compared between survivors and non-survivors in the veno-venous extracorporeal membrane oxygenation (ECMO) cohort.Results: Between April 2020 and April 2021, 52 patients received veno-venous ECMO plus CytoSorb therapy at 5 U.S. centers. ICU mortality was 17.3% (9/52) on day 30, 26.9% (14/52) on day 90, and 30.8% (16/52) at final follow-up of 153 days. Survivors had a trend toward lower baseline D-Dimer levels (2.3 ± 2.5 vs. 19.8 ± 32.2 μg/mL, p = 0.056) compared to non-survivors. A logistic regression analysis suggested a borderline association between baseline D-Dimer levels and mortality with a 32% increase in the risk of death per 1 μg/mL increase (p = 0.055). CytoSorb was well-tolerated without any device-related adverse events reported.Conclusions: CytoSorb therapy for critically ill COVID-19 patients on ECMO was associated with high survival rates suggesting potential therapeutic benefit. Elevated baseline D-Dimer levels may suggest increased risk of mortality. Prospective controlled studies are warranted to substantiate these results.Clinical Trial Registration: <a href="https://clinicaltrials.gov/ct2/show/NCT0439192">https://clinicaltrials.gov/ct2/show/NCT0439192</a>, identifier: NCT04391920.