While critical care medicine has been a recognized and valuable subspeciality of anesthesiology for many years and the scope of practice has expanded, in many respects the recent COVID-19 pandemic has accelerated its transformation. Until recently, and for many practicing critical care anesthesiologists, care focused on addressing acute patient decompensation. Over the past few years, and magnified by the pandemic, care has transitioned to include broader roles in the continuum of illness, whether related to a patient with sepsis, a cardiac surgery patient, neurosurgical patient, or other ICU patient population. In fact, for some critical care anesthesiologists, care is no longer restricted to a specific inpatient environment. Critical care not only includes managing patients across the continuum of inpatient care, but must also consider: roles related to prehospital care and population health, implications of social determinants of health and access to services, short- and long-term outcomes of critical illness, integration of artificial intelligence into practice, and, at the same time, ensure the health and well-being of the clinicians practicing in this intense and stressful environment. This article will address some of these issues and their impact on clinical practice and opportunities for the next decade and beyond.
The expansion of the critical care medicine continuum
The future of critical care medicine and advances in the practice will require a broader focus, including identifying ways to assess patients prior to critical illness or a surgical procedure to reduce complications or risk and optimize outcomes. To do so will require extending care to outpatient, non-hospital environments. One of the keys to providing this broader focus is the use of remote technologies, including a variety of devices used for home monitoring and management (home blood pressure cuffs, pulse oximeters, and ventilatory support devices like CPCP), and the use of wearable technologies. This monitoring capability in the prehospital setting will facilitate identification of patients at risk for developing arrythmias, strokes, progressive respiratory failure, or sepsis. Integration of these data into electronic medical records will become routine, allowing for a more rapid initiation of critical care services prior to hospital transfer. For example, stroke units with imaging technology and community site ECMO cannulation teams will become common. It is likely that drones, with video equipment carrying life-saving supplies, may become part of the first response team often managed by a critical care anesthesiologist.
Critical care and population health
The practice of critical care medicine has traditionally focused on individual patients and physiologic changes. The impact of the COVID-19 pandemic reveals that racial/ethnic, rural, and low-income populations continue to experience suboptimal and limited access to quality health care. Patient surges with limited resources require the creation of local and regional command centers with telemedicine capabilities to predict patient flow, facilitate patient transfers, and identify gaps in post-ICU care. In addition, the pandemic required implementation of triage systems to optimize utilization of limited critical care beds, identification of other ways to manage patients, and engagement other providers with limited experience in the care of critically ill patients to help support overall clinical needs. As a result of these innovative models of care, the value of the critical care anesthesiologist became apparent and facilitated care of a larger, more complex, and diverse patient population than would otherwise have been possible.
In addition to direct ramifications of the COVID pandemic on managing large numbers of critically ill patients, the pandemic also emphasized the importance of communication and transparency to patients and their families. In response to the outcry for transparency, the 21st Century Cures Act provides patients and their families with direct access to their health records. While facilitating this communication with patients and their families, all providers must ensure that the information is accurate, interpretation is provided, and providers are able to communicate how the information will impact clinical decision-making. The Cures Act challenges physicians, including critical care anesthesiologists, to ensure that dissemination of information is meaningful, facilitates coordination of care, and address some of the ethical issues confronting clinicians, patients, and their families.
Advances in medical technology and clinical care have markedly improved survival after critical illness. Long-COVID, “chronically critically ill,” and post-intensive care syndrome (PICS) represent examples of the longer-term implications of critical illness. The improved outcomes have associated challenges, including the high costs and resources needed to manage the sequelae of the acute illness on patients and their families. In addition, patients and their caregivers have to address the associated cognitive dysfunction, inability to work, and impact on personal relationships after surviving an ICU experience.
Future trends in critical care
The next decade of critical care medicine will likely provide additional new and exciting opportunities that will enhance the practice. Some of the changes taking place in health care in general and critical care in particular include the transition to personalized medicine, advanced monitoring and organ support, sustainability in the ICU, and an increased emphasis on improving clinician wellness – all of which will impact critical care practice.
Advancements in personalized medicine will have great value for critically ill patients, though some unique issues must be addressed. As a result of the acute, rapidly evolving nature of critical care, identifying discreet groups of ICU patients and analyzing large volumes of clinical and biological data in real time is not yet feasible. Unlike the approach to personalized medicine for cancer patients, where phenotyping is possible, similar assessments may not be possible during an acute course of care. As technology evolves, is more readily available to the bedside clinician, and costs are reduced, the opportunity to define specific therapies appropriate for an individual patient will hopefully expand. Precision critical care will also require well-designed clinical trials to validate efficacy, define complications and sequelae of interventions, and refine management. To improve bedside practice and transition to more personalized ICU care, research that investigates diagnostic error, barriers to implementing best practices, and resource allocation relative to goals of care will be essential.
Organ support and monitoring
Advances in mechanical and other devices to support patients with organ dysfunction continue to be made with positive implications for patients and providers. Most support systems have become smaller, easier to use, and more environmentally friendly, with improved monitoring capabilities to ensure they are functioning appropriately and minimizing the oversight required by providers. ECMO circuits and other extracorporeal systems can be inserted using minimally invasive approaches. Patients with “artificial hearts” are able to receive support as outpatients. Dialysis systems are more portable and wearable, and easier for patients to use and for physicians to manage. Other technologies are also improving care and providing better delivery and monitoring capabilities. These change are reducing plastic disposable waste as well. Implementation of some of the new support systems will also expand the monitoring capabilities beyond “routine” vital signs. For example, some of the newer ventilator technologies will allow monitoring of parameters not currently available, strain, tidal stress, and mechanical power – assuming that assessing these parameters can be demonstrated to improve management and outcomes.
Advances in biotechnology will enable continuous and remote assessment of cellular function and visualization of the microcirculation. Nanoparticles and materials that provide information about delivery of a drug to a targeted organ site and its therapeutic action will revolutionize how critical care is practiced. The evolution of tissue engineering may allow 3D-printed organs or extracellular matrices to support critically ill patients with organ failure.
Machine learning and artificial intelligence (AI)
The ICU is an outstanding laboratory for advancing machine learning in clinical care. The data-rich environment of the ICU will harness AI tools such as machine learning to aid in clinical decision-making. Potential challenges to the use of AI in the ICU setting include rapidly enabling high-quality data, identifying relevant clinical questions, and navigating the ethical and legal ramifications of a potential AI solution and decision.12
The future of critical care culture
Some additional considerations must be addressed to advance the practice of critical care and its implications for patients, providers, and health systems. Historically, critical care units and critical care physicians utilized the “by any means necessary” ethos to deliver care. While ICU care is costly, cost and its implications are not routinely considered when caring for the individual patient. Critical care physicians utilize the “by all means necessary” ethos to try to achieve the desired goals of care. In addition, concerns about the implications on the environment as well as the well-being of the staff have not been foremost in decision-making. Now and over the next decade, the implications of critical care on cost, the environment, and provider well-being will take on greater significance and raise many associated issues that must be addressed to allow continued advances in care and the resources and workforce to support them.
Sustainability and the implications on use, disposal, and the environment are gaining attention. Life cycle assessments (LCAs) that analyze environmental impact from production to use and ultimately disposal will become routine and affect hospital operations. LCAs of reusable equipment such as laryngoscopes and ventilator circuits must take into account cost and the environmental impact of processing and sterilization, in addition to clinical needs. Efforts to reduce an ICU’s carbon footprint will need to consider issues related to the ICU infrastructure and building maintenance, including heating, air conditioning, and ventilation systems.
The COVID pandemic has underscored the personal cost of the ICU environment on staff. Physician well-being has gained emphasis over the past decade, in part related to duty hours for both trainees and practicing physicians, the impact of sleep deprivation, and other issues that affect the workforce. As a result, the health of the current and future critical care workforce is precarious and will require increasing attention and resources to redesign how care is provided, how to manage increasing transitions of care, and how to most effectively address burnout, moral distress, and other implications. Health systems will face the economic pressure and staffing implications of clinician turnover and will need to invest in systemic changes to reduce this financial impact. As providers struggle with some of the ethical and moral dilemmas associated with understanding and valuing patients’ goals of care, more open dialogue about patient autonomy, futility, and other ethical issues must take place.
With the abundance of external factors that influence the practice of critical care medicine, nimbleness and adaptability to rapidly changing circumstances will be necessary to ensure optimal patient care. Reimagining delivery systems and exciting developments in technology have the potential to transform acute responses in both patient care and health care service delivery. With increasing clinical capabilities, the opportunities in critical care seem limitless – while the resources to address them are limited. Critical care anesthesiologists at the forefront of this dilemma can have a vital role in fostering broad discussions about how to advance care while taking into account the impact of our practices on individual patients, the health system, equity, our communities, and society.