Challenges in Critical Care
The field of critical care medicine, still a relatively young specialty, is growing and changing rapidly with better understanding of pathophysiology, new technology, and improved processes of care. This progress not only has a positive impact on patient care and often on outcomes, but also creates new challenges as we try to encompass new developments into daily practice.
In this issue of Seminars in Respiratory and Critical Care Medicine, we have drawn together experts in different aspects of critical care medicine to examine and discuss some of the many challenges in today's intensive care unit. Recent years have seen a move toward the concept that less may be better in many areas of medicine, including intensive care, in part to reduce iatrogenicity. One aspect where this has really advanced is the field of monitoring with minimally invasive and even noninvasive monitoring systems now widely available for hemodynamic status. How reliable these are compared with invasive devices, which technique is optimal for which patient, and can they be used within closed-loop systems for the management of, for example, blood pressure, are just some of the many questions raised by this development, and several articles are dedicated to these considerations. Advances in technology, notably in computing, have facilitated the collection of huge amounts of patient data, paving the way for new observational research and feeding artificial intelligence to potentially develop new diagnostic tools and therapies. The associated challenges, not least in terms of data sharing and patient privacy, are discussed in two of our articles. New therapies can create new challenges, for example, the ethical implications of stem cell therapies, but established therapies, for example, some vasopressor agents, are not always as safe as we thought, and new trials have raised questions about their role in some or all patients. Sedation has also come under intense debate with the realization of the harmful effects of deep sedation on short- and long-term outcomes, for example, delirium and postintensive care syndrome, and the importance of providing adequate pain control. The metabolic and endocrine issues that have come to the fore in recent years, including advances in metabolomic profiling and the ongoing debate about optimal glycemic control, are considered in another article. Specific groups of intensive care patients, for example, the elderly, and specific conditions, such as traumatic brain injury and life-threatening hemoptysis, also have dedicated articles, and this issue closes with discussion of the many challenges associated with end-of-life issues.
In summary, there are many and varied challenges across the field of critical care medicine—far too many to cover in just one issue. We hope our selection, which may seem a rather heterogeneous assortment, will help trigger further reflection of this huge area, with the realization that as we move forward, further challenges will inevitably arise. Importantly, although often considered as a barrier to progress, challenges should rather be seen as providing an opportunity to encourage debate and discussion to resolve difficult issues and thus improve our clinical practice and patient management.
We would like to thank all the authors for their excellent contributions and the editorial staff at Seminars for their assistance and patience.
03 November 2020 (online)
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