The Future of Critical Care Medicine
Dr. Mohamed Makarim
Consultant Intensivist
Since the inception of human existence, each generation has experienced progressions and improvements relevant to its time. In the same way, advancement and growth in the field of critical care have progressed leaps and bounds over the preceding century, vastly relying on technological breakthroughs. We will not precisely understand how the penetration of technical concepts and theories will shape human life in the following years. However, the quality discrepancies will inevitably be more marked than ever before in providing critical care services worldwide between developed and resource-poor countries.
Figure 1: Market driving forces
Equipment and machinery
Intensive-care units (ICUs) and equipment used in ICUs like in many other medical fields would have undergone enormous changes, thanks to the technological developments that catalysed medical equipment innovation. The metamorphosis of these types of machinery will depend on changing technology, market dynamics, market drivers, disease patterns, and stringent regulatory and statutory compliance requirements. As a result, ICU’s of the future will be equipped with equipment and machinery designed based on market driving forces to cater critically ill of the future.
Advanced Informatics
Intensive-care units (ICUs) and equipment used in ICUs like in many other medical fields would have undergone enormous changes, thanks to the technological developments that catalysed medical equipment innovation. The metamorphosis of these types of machinery will depend on changing technology, market dynamics, market drivers, disease patterns, and stringent regulatory and statutory compliance requirements. As a result, ICU’s of the future will be equipped with equipment and machinery designed based on market driving forces to cater critically ill of the future.
ICU middleware (software that acts as a bridge between applications in a network) will potentially perform many functions that will advance ICU care and management. Alarm systems will capture alerts and convert them into actionable information by filtering and transmitting them to dedicated receivers and personnel. Intelligent alarm systems will even analyse raw device data and generate personalised alarms. Data “sniffers” will monitor ICU data and the EMR and profile patients at risk for clinical deterioration.
Real-time locating systems/solutions (RTLS) will improve management and workflow by tracking or finding tagged assets, monitoring device utilisation and controlling product inventory. RTLS will also be integrated with existing systems to enhance personnel location, infection control, and patient room management.
Devices (e.g., all ventilators) will be monitored by middleware, thereby supporting global device viewing (i.e., local telemedicine), alarm transmission, report generation, and remote troubleshooting. Lastly, ICU middleware will produce smart displays that merge data from bedside devices and the EMR and process these data through artificial intelligence algorithms to support clinicians’ decision making.
Patient area of a modern ICU
Monitoring
Monitoring of a future ICU will largely depend on noninvasive methodologies. With the availability of advanced bedside imaging modalities, access to real-time anatomical images will readily be displayed on OLED screens.
Restoration of the function of the microcirculation will be the therapeutic target for the future of resuscitation. Detection of an organ-specific microcirculatory dysfunction will play a pivotal role to aid diagnosis and risk stratify critically ill patients. Direct measures of the microcirculation will encompass techniques involving highly sensitive video microscopes providing in vivo visualisation of the microcirculation, allowing direct measurement of capillary density, perfusions, and flow dynamics. Along with continuous ‘static’ measurements of tissue oxygenation, ‘dynamic’ measures will be obtained. The above steps will allow us to interrogate the function of microcirculation in more detail.
Metabolism monitoring will be another modality used in critically ill to diagnose infection, determine the phase of critical illness, and guide post-ICU rehabilitation. For example, trending of the 13CO2/12CO2 ratio in exhaled gas to assess inflammatory and feeding status and fat oxidation rate versus carbohydrate oxidation rate helping to characterise tissue vitality and rehabilitation progress, and thereby help shape targeted exercise/ nutritional/ hormonal programs to aid faster recovery from critical illness.
ICUs will also have access to the network of built-in database repositories where every vital sign, clinical finding, and patients note will be continuously recorded and stored for real-time analyses to match subtle trends to allow for more accurate and timely diagnosis of many different disease states. These data will allow for a more thorough understanding of disease onset and progression and thus will facilitate earlier and more efficacious treatment. This information will be analysed and displayed on the OLED screens with crucial details and the highlighted patient’s predicted trends valid for the future intensivist.
Organ support
The development of miniaturised technologies would be a significant advance in the field of Medicine. As a result, Organ support, the cornerstone of ICU care, will depend on organ modules/” organ similars” coordinated by middleware untangling the mystery of organ crosstalk to make our understanding better to simplify the decision making process error-free.
One time intravascular access ports (IAP) will get inserted under robotic guidance for sampling, administrative and therapeutic procedures. IAPs would be a device with inbuilt filters for infection and thromboembolic complication prevention, anchored and safely connected to the ICU bed vascular module. The vascular module will use this port with intelligence, eliminating the problems of entangled multiple lines, drug incompatibilities and the need for frequent disconnections and reconnections.
Better resuscitation fluids for shock will be available that improve perfusion, boost oxygen delivery and reduce inflammation, ensuring microcirculatory and tissue protection. Besides, specific types of fluids will be available to target the particular physiological compartment of the individual patient in need of resuscitation will be used. The compartments which will be identified include intracellular, interstitial and intravascular compartments.
With the application of nanotechnology and microfluidics to renal replacement therapy (RRT), newer approaches, including the human nephron filter, a novel form of RRT consisting of 2 membranes in series, will be available for the critically ill. Using both sorbent-based techniques and membrane-based reclamation of spent fluid will reduce the volume of effluent generated during CRRT and other dialysis modalities revolutionising RRT in future ICU.
Though most patients will be managed with noninvasive respiratory support modalities, patients need for ventilators will be still felt. Modern ventilators will have the predictive ability of patient requirements and support accordingly, synchronised with other organ support modules to help to provide adequate and humane care. In severe illness, there is always the possibility of using extracorporeal lung/renal/metabolic support modules to support critically ill-used in combination with ventilators.
Bed rest will no longer be considered a benefit, and patients will only be allowed to stay in bed at night where they sleep following exogenously administered melatonin. Since better sleep should speed up recovery and help prevent post-ICU syndrome, melatonin will play an integral role in modern ICUs. Bed rest will also be allowed if the patient is in shock or in a coma. As soon as a patient getting admitted to an ICU, a physiotherapist will introduce the patient to a personalised robot application that would help the patient to exercise and walk. It will even allow the patient to get out into the landscaped garden surrounding the ICU when the local weather permits.
P Medicine
Contrary to the current modus operandi of modern Medicine, predicated on the Cniderean School of Medicine concept, “P-Medicine” will emerge. The P-Medicine list of endeavours includes Personalised, Precision, Preventive, Predictive, Pharmaco-therapeutic and Patient Participatory Medicine.
In modern critical care, any treatment the patient receives will require coupling with their stereotype subgroup. They will be part of a clinical trial/data bank, and that all hospitals are linked as part of a clinical trials network. Bedside clinicians will precisely define the patients’ stereotype subgroup from the databases that are available, considering both the ‘omics’ pathway (genetics, genomics, proteomics, and other molecular component levels) and the demographics pathways.
As specific subgroups are more defined, the interventions and treatments will inherently be more precise and can be applied to particular patients. Once these subgroups were identified, then the use of computational modelling and predictive computing will help determine treatment and outcome. This approach will advance medical care for real-time data interpretation, preventing delays in analysis and publications, and the results can be better individualised. As a result, all these measures will lead to precision and personalised Medicine for the critically ill instead of protocol-driven patient management.
Ethical dilemmas
Ethical arguments will continue defining death/withholding and withdrawal of treatment with the advent of ‘organ similars.’ Remedying these problems will largely depend on advanced patient directives, which will be considered a statutory obligation.
Conclusion
The future of critical care will get its shape by the technological concepts penetrating the field of Medicine, limiting the role of an intensivist to a manager of a complex IT system to provide error-free, effective and humane care to the critically ill.
