Editorial introductions

Editorial introductions

Burnout Syndrome in ICU Caregivers: Time to Extinguish!

Point-of-care ultrasound (POCUS) is an integral aspect of critical care and emergency medicine curriculums throughout the country, but it has been slow to integrate into internal medicine residency programs. POCUS has many benefits for internal medicine providers, guiding diagnostic decisions and aiding in procedures. Additionally, POCUS is a convenient and portable resource specifically for internal medicine providers in the military when practicing in deployed or critical care settings. Critical care and emergency medicine clinicians are excellent resources to lead these courses. We sought to develop a new POCUS curriculum for internal medicine residents within the Naval Medical Center Portsmouth Internal Medicine Residency program with the support of emergency medicine and critical care medicine staff to lead and oversee the training. The project's aim was to increase internal medicine resident confidence with POCUS by 20% and proficiency with POCUS as evidenced by pretest and posttest analysis by 10%. The program consisted of a 2-day, 9-hour, introductory course, combining lecture with hands-on scanning taught by emergency medicine physicians who had completed emergency ultrasound fellowship-level training. This was followed by a longitudinal component of hands-on scanning throughout the academic year built into the residents' schedules. Emergency and critical care medicine ultrasound staff reviewed all studies for quality assurance (QA). The residents were given both precourse and post-course knowledge tests and confidence surveys, which utilized a 5-point Likert scale. The knowledge assessments were analyzed with a paired t-test, and the Likert scale data were analyzed using the Wilcoxon signed-rank test. The Naval Medical Center Portsmouth Institutional Review Board deemed this project nonhuman subjects' research. Twenty participants were enrolled, with 10 (50%) of those enrolled completing all course requirements. The average precourse knowledge assessment score was 76.60%, and postcourse assessment score was 80.95% (+4.35%, P = .33). The confidence survey scores were initially 73.33% and improved to 77.67% (+4.34%, P = .74). A curriculum comprised of a 9-hour workshop followed by a longitudinal hands-on experience can provide improvement in internal medicine resident POCUS knowledge and confidence. This model emphasizes the benefit of emergency and critical care cooperation for ultrasound training and provides an emphasis on medicine-relevant scans and longitudinal training.

The COVID-19 pandemic precipitated a significant transformation of scientific journals. Our aim was to determine how critical care (CC) journals and their impact may have evolved during the COVID-19 pandemic. We hypothesized that the impact, as measured by citations and publications, from the field of CC would increase. Observational study of journal publications, citations, and retractions status. All work was done electronically and retrospectively. The top 18 CC journals broadly concerning CC, and the top 5 most productive CC journals on the SCImago list. None. For the top 18 CC journals and specifically Critical Care Medicine (CCM), time series analysis was used to estimate the trends of total citations, citations per publication, and publications per year by using the best-fit curve. We used PubMed and Retraction Watch to determine the number of COVID-19 publications and retractions. The average total citations and citations per publication for all journals was an upward quadratic trend with inflection points in 2020, whereas publications per year spiked in 2020 before returning to prepandemic values in 2021. For CCM total publications trend downward while total citations and citations per publication generally trend up from 2017 onward. CCM had the lowest percentage of COVID-related publications (15.7%) during the pandemic and no reported retractions. Two COVID-19 retractions were noted in our top five journals. Citation activity across top CC journals underwent a dramatic increase during the COVID-19 pandemic without significant retraction data. These trends suggest that the impact of CC has grown significantly since the onset of COVID-19 while maintaining adherence to a high-quality peer-review process.

The Critical Care Family Assistance Program: Caring For Those Who Care

Review of the history and accomplishments of the Society of Critical Care Medicine (SCCM) to determine appropriate directions for the future. Historical documents of the SCCM, Critical Care Medicine, bioethics and healthcare financing literature, Instant Library of Quotations. Identified (by the author) material containing specific statements concerning goals and objectives at the time of the founding of the SCCM and at intervals. Material supporting and criticizing predictive indices were identified and bioethical treatises concerning patient autonomy and quality-of-life decisions were chosen. Presidential addresses of the first three SCCM presidents, material relevant to preservation of life and alleviation of suffering from bioethical and healthcare financing perspectives. Relevant quotations. Initial goals and objectives were identified. Societal and economic factors changing critical care were analyzed for their effect on current and future SCCM directions and objectives. The founding members set important goals for critical care and patient care, research, education, and organization. From a perspective of what was foreseeable, these goals have been accomplished to an admirable degree. The SCCM has responded to these goals by providing educational programs and fostering research, especially in its annual meetings and through the publication of guidelines in Critical Care Medicine. The SCCM members would do well to read the first three presidential addresses to experience the eloquence and foresight firsthand, particularly with respect to the founders' spirit, considerations of training, scope of care, humanism, organization and relations within and outside of critical care, integration of care, and development of the scientific process at the bedside. There have been major changes in society since the SCCM was founded: the maturation of the concept of patient's autonomy; recognition of quality-of-life values; healthcare financing; and legal and ethical aspects of care. The critical care profession in general, and the SCCM specifically, should seek to develop effective cost-containment strategies and severity of illness or predictive indices. The SCCM should also educate the professions with respect to ethical issues and provide information directly to the public, especially in the areas of advance directives and withholding and withdrawing care. Through these contributions, the SCCM can assume its proper leadership role within medicine, but, of greater importance, in society. In doing so, societal myths and misunderstandings of the capabilities, futility, role, and limitations of critical care can be corrected. The organization and structure of the SCCM are well developed to accomplish these ends. The SCCM leaders are both able and willing. The objectives seem reasonable and should be attainable.

On the 50th anniversary of the Society of Critical Care Medicine's journal Critical Care Medicine, critical care pioneers reflect on the importance of the journal to their careers and to the development of the field of adult and pediatric critical care.

European guidelines on perioperative venous thromboembolism prophylaxis.

Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, CA Division of Infectious Diseases, University of California, San Diego, La Jolla, CA; and Critical Care Medicine Department Clinical Center, National Institutes of Health, Bethesda, MD Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, CA *See also p. 291. Dr. Malhotra received support for article research from the National Institutes of Health (NIH). The remaining authors have disclosed that they do not have any potential conflicts of interest. The opinions expressed in this article are the authors’ own and do not represent any position or policy of the NIH, the Department of Health and Human Services, or the U.S. government.

Percutaneous dilatational tracheostomy (PDT) is one of the most common bedside surgical procedures performed in critically ill adult patients on intensive care units (ICUs) who require long-term ventilation. PDT is generally associated with relevant life-threatening complications (e.g. cuff rupture leading to possible hypoxia or aspiration, puncture of the oesophagus, accidental extubation, mediastinitis, pneumothorax, emphysema). The patient's airway can be secured with an endotracheal tube (ETT) or a laryngeal mask airway (LMA). To assess the safety and effectiveness of ETT versus LMA in critically ill adult patients undergoing PDT on the ICU.This review addresses the following research questions.1. Is an LMA more effective than an ETT in terms of procedure-related or all-cause mortality?2. Is an LMA safer than an ETT in terms of procedure-related life-threatening complications during a PDT procedure?3. Does use of an LMA influence the conditions for performing a tracheostomy (e.g. duration of procedure)? We searched the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 6 (part ofThe Cochrane Library); MEDLINE (from 1984 to 27 June 2013) and EMBASE (from 1984 to 27 June 2013). We searched for reports of ongoing trials in the metaRegister of Controlled Trials (mRCT). We handsearched for relevant studies in conference proceedings of the International Symposium on Intensive Care and Emergency Medicine (ISICEM), the Annual Congress of the European Society of Intensive Care Medicine (ESICM), the Annual Congress of the Society of Critical Care Medicine (SCCM), the American Thoracic Society (ATS) and the Annual Meeting of the American College of Chest Physicians (ACCP). We contacted study authors and experts concerning unpublished data and ongoing trials. We searched for further relevant studies in the reference lists of all included trials and of relevant systematic reviews identified in theCDSR. We included randomized controlled trials (RCTs) that compared use of endotracheal tubes versus laryngeal mask airways in critically ill adult patients undergoing PDT on the ICU. We imposed no restrictions with regard to language, timing or technique of PDT performed. Two review authors independently assessed the eligibility and methodological quality of each study and carried out data extraction. We resolved disagreements by discussion. Our primary outcomes were all-cause mortality, procedure-related mortality and tally of participants with one or more serious adverse events. When available, we reported on our secondary outcomes, which included duration of the procedure, failure of the procedure requiring conversion to any other procedure, time to extubation after tracheostomy, length of ICU stay after tracheostomy, length of hospital stay after tracheostomy and any other serious adverse events. When possible, we combined homogeneous studies for meta-analysis. We used the risk of bias tool of The Cochrane Collaboration to assess the internal validity of all included studies in six different domains. We included in this review eight RCTs involving 467 participants. The included trials exclusively assessed critically ill participants (e.g. with head injury, neurological disease, multi-trauma, sepsis, acute respiratory failure (ARF) and/or chronic obstructive pulmonary disease (COPD)). Internal validity was considerably low in studies with a high or unclear risk of bias. The main reason for this was low methodological quality or missing data, even after study authors were contacted. Study size was generally small, with a minimum of 40 and a maximum of 73 participants. Only one study (40 participants) reported on overall mortality, showing no clear evidence of a difference between treatment groups (risk ratio (RR) 1.5, 95% confidence interval (CI) 0.28 to 8.04, Fisher test P value 1.0, low-quality evidence). Four studies (231 participants) reported that no procedure-related deaths occurred with any intervention. Seven studies reported the numbers of participants with adverse events, showing no clear evidence of benefit of either LMA or ETT during PDT (RR 0.73, 95% CI 0.35 to 1.52, P value 0.41, low-quality evidence). The tally of participants in included studies with adverse events ranged from 0% to 33% in the LMA group and from 0% to 50% in the ETT group. However, the duration of the procedure was significantly shorter in the LMA group (mean difference (MD) -1.46 minutes, 95% CI -1.92 to -1.01 minutes, 324 participants, P value ≤ 0.00001, low-quality evidence). No clear evidence of a difference between ETT and LMA groups was found for all other outcomes. Only one study provided follow-up data for late complications related to the intervention, showing no clear evidence of benefit for any treatment group. Evidence on the safety of LMA for PDT is too limited to allow conclusions to be drawn on its efficacy or safety compared with ETT. Although the LMA procedure is shorter because of optimal visual conditions, its effect on especially late complications has not been investigated sufficiently. Studies focusing on late complications and relevant patient-related outcomes are necessary for definitive conclusions on safety issues related to this procedure.

It is a pleasure to announce the 2nd Innsbruck Hypothermia Symposium. We are very happy that Critical Care has agreed to publish extended abstracts submitted by invited renowned scientists from all over the world; that is, Europe, the Americas, Asia. Neuroprotection - potentially achieved by targeted temperature management (that is, therapeutic hypothermia or prophylactic controlled normothermia) - is essential in emergency and acute care management of various severe neurologic and cardiologic diseases. Beyond neuroprotection - for this aim, therapeutic hypothermia has been established after resuscitation of patients with cardiac arrest due to a shockable arrhythmia and in neonatal asphyxic encephalopathy - therapeutic hypothermia and prophylactic controlled normothermia have been published in single case reports, retrospective, open, but also in prospective randomised controlled trials in many other emergency disciplines in which both neuroprotection and protection of other organs and tissues are the target of our therapeutic endeavours. The Medical University Innsbruck, Austria, is happy to organise this conference on temperature management, therapeutic hypothermia and prophylactic normothermia respectively, to be held in Portoroz, Slovenia. In accordance with the first Meeting on Hypothermia, which was held in Miami, Florida, USA (CHilling At the Beach), we are proud to suggest the acronym CHAB standing for take Care for Heart And Brain, characterising the major target organs of therapeutic and, possibly also, prophylactic temperature management. Again, we have been able to gather most renowned scientists, neurointensivists and intensivists, emergency physicians, cardiologists and other specialists to cover the entire scientific and clinical spectrum of emergency temperature management, technical aspects of cooling and management of potential complications including shivering, but also temperature management in neurology, neurosurgery, intensive care medicine, in the operation theatre, cardiology, infectious diseases, and so forth. Beyond that we cross borders and discuss hypothermia and intracranial pressure, pharmacodynamics in hypothermic patients and the influence of hypothermia onto pharmacokinetics/pharmacodynamics, hypothermia in refractory status epilepticus or heat stroke, hypothermia and advanced neuromonitoring, hypothermia and nutrition, shivering and the critical issue of rewarming, amongst other topics. The aim of this symposium is to enhance the knowledge on temperature management, increase the readiness and stimulate the preparedness to institute therapeutic hypothermia and/or prophylactic controlled normothermia, respectively, in patients in need of tissue and organ protection, uncontrolled body temperatures possibly adding - per se - to neuronal damage. Knowing the medical literature and knowing the issue of potentially life-threatening side effects and complications incurred by this invasive therapeutic manoeuvre, it is the foremost aim of this symposium and this supplementary issue of Critical Care to discuss all these aspects of targeted temperature management in emergency, critical care and, in particular, neurocritical patients and conditions. For this reason the organisers have agreed that the discussion of these various issues, being so important for general critical care, neurocritical care and emergency medicine, must be distributed as widely as possible, making it available to critical care and neurocritical care specialists all over the world. Therefore we are extremely grateful to the Editors of Critical Care for providing a forum for all of the extended abstracts of all invited speakers, covering the entire field of adult emergency and critical care medicine. We do hope and we are convinced that this supplementary issue will be a source of inspiration and knowledge, hopefully becoming a work of reference for intensivists, neurologists, neurointensivists, cardiologists and all emergency physicians alike. It is the aim of the organisers to establish a series of such symposia within the next years in order to keep up with all the developments in this field and to maintain the highest possible level of knowledge of targeted temperature management in the community of emergency and intensive care physicians.

Patient Dumping: The Physician's Dilemma

PCCM at the Battlefront Against COVID-19 in Wuhan, China

Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.

FOR A QUARTER CENTURY, JAMA HAS SERVED AS A VENUE for articles relating to care of critically ill patients, beginning with the Concepts in Emergency and Critical Care section, in which these fields were initially described as “spanking new medical disciplines.” At the time, knowledge of the biology of critical illness was rudimentary, the focus was on initial patient care, such as airway management and resuscitation, and the few physicians trained in emergency or critical care medicine worked mainly in large teaching hospitals. During the following years, critical care and emergency medicine grew rapidly, training and accreditation became more standardized, and the focus changed to the definition, management, and outcome of postresuscitation syndromes, such as sepsis, shock, and organ dysfunction. Approximately 10 years ago, the section name was changed to Caring for the Critically Ill Patient, ushering in increased focus on high-quality multicenter randomized trials, organization and delivery of care, and attention to patient-centered outcomes. Today, the Caring for the Critically Ill Patient section of JAMA is devoted to publication of important articles in critical and emergency care at a time when the clinical and research landscape has shifted again. Advances in molecular biology now provide a wealth of information on the humoral and cellular responses to acute trauma, infection, and ischemia. This understanding has helped delineate the mechanisms of shock, sepsis, and organ dysfunction syndromes, such as acute respiratory distress syndrome (ARDS), acute renal failure, and traumatic brain injury, generating a plethora of therapeutic targets. The scale of critical care and emergency medicine services has also changed. Every acute care hospital in the United States boasts an intensive care unit (ICU), half of the nation’s ICU beds are located in small hospitals, and many teaching hospitals have built huge ICU services, often with 60 or more beds. Six million Americans, or 2% of the population, are admitted to the ICU each year, severe sepsis and ARDS affect hundreds of thousands of individuals annually, and 1 in 5 Americans receive ICU care at the end of life. All this care is provided by a workforce of hundreds of thousands of highly trained physicians, nurses, and allied health care personnel who function in integrated team systems, not just in the ICU and emergency department, but increasingly on hospital general units and in the community. With substantial investment of resources and advancement in knowledge, care of critically ill patients has no doubt improved. Mortality appears to have decreased for sepsis and ARDS, and headway has been made toward safer, quicker, more effective care. However, considerable challenges lie ahead on the path from basic science to improved public health, including a translational block between basic science and clinical trials; challenges in conducting clinical trials in critically ill patients; failure of clinical research to fully frame health issues facing critically ill patients; an inadequate evidence base for many aspects of care; and public health policy that is either lacking or uninformed by evidence. The first challenge, overcoming translation from basic science to clinical trials, is exemplified by the sepsis syndromes. Among the more than 30 large trials involving agents designed to modify the host response to infection, only 2 were positive (and neither of these are considered definitive). While trial design may be partly to blame, the problems run deeper. Severe sepsis, the subset of sepsis with acute organ dysfunction, is often difficult to define and encompasses a highly heterogeneous group of patients. Outcome and probably response to therapy are linked to multiple host, pathogen, and health care–related factors that neither in vitro nor in vivo models adequately address. Therapies enter clinical trials with little information on appropriate dosing or methods to monitor their biologic activity. A particular challenge for sepsis and other critical illnesses is that the pathways targeted for modification are as often helpful as harmful, and current clinical trial entry criteria provide no guarantee that the host response pathway of interest is either active in a particular patient or behaving in an injurious manner. Thus, clinical research needs better tools to select and monitor patients and their therapies, and basic science needs