Crit Care Clin
· 2026 Apr · PMID 41825983
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Critical care medicine is undergoing a major transformation driven by rapid technological innovation, digital integration, and telemedicine. This article examines how modern intensive care units (ICUs) are evolving into...Critical care medicine is undergoing a major transformation driven by rapid technological innovation, digital integration, and telemedicine. This article examines how modern intensive care units (ICUs) are evolving into data-rich, precision environments equipped with advanced monitoring, organ support, and predictive analytics. Innovations such as artificial intelligence-enhanced decision support, portable ultrasound, and tele-ICU platforms are expanding diagnostic accuracy, remote access, and timely interventions. By tracing historical milestones to emerging technologies like smart ICUs and wearable biosensors, this article highlights the shift toward anticipatory, personalized care. It underscores the importance of evidence-based adoption to ensure these tools improve outcomes.
Regionalization of critical care re-engineers intensive care unit (ICU) delivery by linking quaternary hubs and community hospitals through tele-ICU, command centers, predictive analytics, shared triage protocols, and ke...Regionalization of critical care re-engineers intensive care unit (ICU) delivery by linking quaternary hubs and community hospitals through tele-ICU, command centers, predictive analytics, shared triage protocols, and key performance indicators (KPIs). This network optimizes resource allocation, reduces mortality, shortens length of stay, boosts contribution margin, and preserves surge capacity. Six foundational domains-clinical/operational alignment, infrastructure and logistics, digital enablement, governance, return on investment/value, and KPIs-offer a pragmatic roadmap for scalable, high-reliability care. Executives must codify governance, invest in digital backbone, embed actionable metrics, and foster cross-site culture to transform critical care into a resilient, value-driven enterprise for future-ready sustainability.
Optimizing drug dosing in critically ill patients is complex due to dynamic changes in pharmacokinetics and pharmacodynamics driven by disease-related physiology and interventions such as extracorporeal devices. Inadequa...Optimizing drug dosing in critically ill patients is complex due to dynamic changes in pharmacokinetics and pharmacodynamics driven by disease-related physiology and interventions such as extracorporeal devices. Inadequate dosing may lead to therapeutic failure, whereas excessive dosing can exceed the patient's physiologic reserve, increasing the risk of adverse effects. As the medication experts on the interprofessional ICU team, critical care pharmacists are uniquely equipped to address the complex pharmacotherapeutic needs of critically ill patients. Key responsibilities include proactive medication management; providing education to clinicians, patients, and families; addressing drug-related questions; guideline development and implementation; and monitoring medication safety and efficacy.
Advanced practice providers (APPs) are integral to modern critical care delivery. APP leaders bridge bedside expertise with systems-level improvement, strengthening clinical outcomes, operational reliability, team cultur...Advanced practice providers (APPs) are integral to modern critical care delivery. APP leaders bridge bedside expertise with systems-level improvement, strengthening clinical outcomes, operational reliability, team culture, and financial performance. Evidence from acute and critical care consistently links APP-integrated models to reduced mortality and length of stay, improved adherence to clinical practice guidelines, fewer hospital-acquired complications, and enhanced patient and staff satisfaction. This article synthesizes the rationale, structures, and strategies for high-impact APP leadership in critical care, incorporating programmatic insights from the author's fellowship experience and offering practical tools to design, measure, and sustain high-reliability APP-led models.
Competency assessment in critical care has evolved from subjective evaluations to more structured discipline-specific competency-based frameworks. However, significant variability among disciplines persists. Workforce sh...Competency assessment in critical care has evolved from subjective evaluations to more structured discipline-specific competency-based frameworks. However, significant variability among disciplines persists. Workforce shortages, growing patient complexity, and increasing reliance on interprofessional models underscore the need for standardized, adaptable, and team-focused frameworks. Lessons from aviation and the military highlight the importance of structured, role-agnostic assessments. To ensure safe, high-quality care, competency assessment must move beyond discipline-specific models toward collaborative, real-world, and outcome-oriented approaches that address the dynamic needs of modern critical care and the rapidly changing health care environment overall.
Establishing a critical care organization (CCO) requires administrative, clinical, and financial alignment across traditionally independent and self-contained hospital departments. Success depends on stakeholder engageme...Establishing a critical care organization (CCO) requires administrative, clinical, and financial alignment across traditionally independent and self-contained hospital departments. Success depends on stakeholder engagement, integration of resources, clear revenue, and compensation models, and standardized clinical protocols supported by robust data oversight. A CCO fosters multidisciplinary collaboration among physicians, nurses, therapists, and support services, promoting transparency, quality, and shared ownership. Despite implementation challenges, a CCO can unify intensive care unit services into a cost-effective, efficient, and academically driven model that enhances outcomes for patients, providers, and health systems.
In this article, we outline the evolution of critical care delivery and organization and propose roadmap and practical strategies, with real-world examples, for building functional and high-performing intensive care unit...In this article, we outline the evolution of critical care delivery and organization and propose roadmap and practical strategies, with real-world examples, for building functional and high-performing intensive care unit (ICU) systems through 10 organizational principles that lay the groundwork for creating critical care organizations that are efficient, patient-centered, and sustainable. We conclude with a forward-looking vision of future ICU organizational care, emphasizing innovation, technology, workforce resilience, and global equity.
Crit Care Clin
· 2026 Jan · PMID 41260719
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Cardiac arrest (CA) remains a major cause of mortality and neurologic impairment, underscoring the urgent need for innovative neuroprotective strategies. Gas therapies, including inhaled nitric oxide (NO), molecular hydr...Cardiac arrest (CA) remains a major cause of mortality and neurologic impairment, underscoring the urgent need for innovative neuroprotective strategies. Gas therapies, including inhaled nitric oxide (NO), molecular hydrogen (H), xenon (Xe), and argon (Ar), have emerged as promising neuroprotective agents. These gases exert protective effects, preserving neurologic function and improving outcomes after CA through antioxidant, anti-inflammatory, and anti-apoptotic mechanisms. Despite promising preclinical and early clinical data, large-scale trials are essential to validate their efficacy, optimize protocols, refine dosing, and ensure clinical translation. Advancing gas therapies into standard post-CA care could revolutionize neuroprotection, offering a paradigm shift in resuscitation medicine.
Lupton JR, Magliocca A, Daya MR
… +2 more, Dorian P, Cheskes S
Crit Care Clin
· 2026 Jan · PMID 41260718
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The most critical intervention for patients suffering cardiac arrest due to ventricular tachyarrhythmias is timely defibrillation. We present a comprehensive review on current external defibrillation strategies, includin...The most critical intervention for patients suffering cardiac arrest due to ventricular tachyarrhythmias is timely defibrillation. We present a comprehensive review on current external defibrillation strategies, including issues of access to and use of defibrillators, to maximize patient survival after cardiac arrest. Successful defibrillation depends on an electrical shock delivered with sufficient shock strength, vector, and waveform characteristics to a heart with a metabolic state capable of returning to an organized rhythm. Finally, access to and application of automated external defibrillators should remain a significant public health priority to reduce time to initial defibrillation in patients suffering cardiac arrest.
Crit Care Clin
· 2026 Jan · PMID 41260717
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Survival of refractory non-traumatic out-of-hospital cardiac arrest (OHCA) remains low despite many advances in care. Extracorporeal cardiopulmonary resuscitation (ECPR) has demonstrated the ability to significantly impr...Survival of refractory non-traumatic out-of-hospital cardiac arrest (OHCA) remains low despite many advances in care. Extracorporeal cardiopulmonary resuscitation (ECPR) has demonstrated the ability to significantly improve outcomes in select patients suffering refractory OHCA. These trials highlight different, but important, aspects of ECPR and provide insights into how we should design future ECPR systems of care. As the use of ECPR increases, this article updates the state-of-the-art in ECPR for refractory OHCA, highlighting the critical components of contemporary ECPR systems of care, clinical controversies in post-resuscitation strategies, and future areas of research needed.
Crit Care Clin
· 2026 Jan · PMID 41260716
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Cardiac arrest survivorship is an evolving field focusing on long-term recovery, encompassing physical, cognitive, and psychological health. Despite increased survival rates, many survivors face challenges such as cognit...Cardiac arrest survivorship is an evolving field focusing on long-term recovery, encompassing physical, cognitive, and psychological health. Despite increased survival rates, many survivors face challenges such as cognitive impairment, emotional distress, mobility issues, and caregiver burden. Current follow-up care has limited structured screening and multidisciplinary support. A pilot recovery program at a single center demonstrated high rates of cognitive impairment and readmissions, highlighting the need for comprehensive post-intensive care unit clinics, nurse navigation, and targeted interventions. Key research priorities include long-term outcome studies, rehabilitation strategies, telemedicine, caregiver support, and cost-effectiveness analyses to optimize survivor care and improve quality of life.
Crit Care Clin
· 2026 Jan · PMID 41260715
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Cardiac arrest is a significant public health issue, with high associated morbidity and mortality. However, it is a modifiable disease process, with a better chance of a good outcome when high-quality cardiopulmonary res...Cardiac arrest is a significant public health issue, with high associated morbidity and mortality. However, it is a modifiable disease process, with a better chance of a good outcome when high-quality cardiopulmonary resuscitation is provided. Despite clear guidelines, gaps in translating these recommendations into practice remain prevalent. Effective implementation requires addressing these complex sociotechnical scenarios using comprehensive approaches informed by the principles of disciplines such as implementation science (IS). IS, which promotes the systematic uptake of evidence-based practices into routine practice, is well-suited for the challenges of implementation in emergency cardiovascular care and has been underutilized to date.
Buckley RJ, Yang D, D'Onofrio G
… +1 more, Perman SM
Crit Care Clin
· 2026 Jan · PMID 41260714
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This article reviews the multifaceted landscape of overdose-associated out-of-hospital cardiac arrest in the context of the ongoing opioid epidemic and opioid-associated. It synthesizes current knowledge on epidemiology,...This article reviews the multifaceted landscape of overdose-associated out-of-hospital cardiac arrest in the context of the ongoing opioid epidemic and opioid-associated. It synthesizes current knowledge on epidemiology, pathophysiology, prehospital and hospital management, outcomes, and prevention strategies. The article emphasizes the clinical nuances of polysubstance overdoses, postarrest care, and highlights critical gaps in research, especially around naloxone use and postresuscitation care.
Crit Care Clin
· 2026 Jan · PMID 41260713
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Neuroprognostication characterizes the potential for functional recovery in patients who remain unconscious after cardiac arrest. Prognostic impressions heavily influence goals-of-care decisions: Patients deemed to have...Neuroprognostication characterizes the potential for functional recovery in patients who remain unconscious after cardiac arrest. Prognostic impressions heavily influence goals-of-care decisions: Patients deemed to have a favorable recovery potential are often supported through their convalescence journey whereas patients with unfavorable prognosis are transitioned to a comfortable, dignified end-of-life, whenever aligned with their values. No single prognostic test modality is reliable predicting outcomes as subjective and/or unaccounted factors challenge the prediction performance of prognostic tools; hence, multimodal approaches to neuroprognostication are essential to mitigate inaccuracies. Furthermore, understanding meaningful recovery from a patient-centered perspective is critical for personalized decision-making.
Crit Care Clin
· 2026 Jan · PMID 41260712
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The increasing use of left ventricular assist devices (LVADs) for advanced heart failure presents new challenges in emergency care, especially during cardiac arrest. LVAD-supported patients often lack palpable pulses and...The increasing use of left ventricular assist devices (LVADs) for advanced heart failure presents new challenges in emergency care, especially during cardiac arrest. LVAD-supported patients often lack palpable pulses and may have unreliable blood pressure readings, complicating diagnosis. Management strategies vary, with debates over whether to delay chest compressions to troubleshoot the device or initiate immediate resuscitation. Recognizing cardiac arrest involves alternative assessments like end-tidal co and ultrasound. Limited evidence and inconsistent guidelines highlight the need for standardized protocols, training, and large registries to improve outcomes and guide best practices for prehospital and hospital management of LVAD patients experiencing cardiac emergencies.
Crit Care Clin
· 2026 Jan · PMID 41260711
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Since the first successful organ transplant in the 1950s, considerable good has occurred by saving the countless lives of those who would have otherwise succumbed had it not been for this unique gift of life. Medicine ha...Since the first successful organ transplant in the 1950s, considerable good has occurred by saving the countless lives of those who would have otherwise succumbed had it not been for this unique gift of life. Medicine has come full circle- uniting the end of one life (cardiac arrest) with the renewed chance of extending the life of another (organ donation after circulatory death). This paper addresses the ethical issues that arise in the transition, respecting our attending need to: first do no harm.
Ross CE, Lee JH, Loaec M
… +3 more, Valdés SO, Donnino MW, Berg RA
Crit Care Clin
· 2026 Jan · PMID 41260710
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In this article, we describe the potential for personalized cardiopulmonary resuscitation using physiology to guide drug administration. We also highlight the limitations of the current evidence to inform a more individu...In this article, we describe the potential for personalized cardiopulmonary resuscitation using physiology to guide drug administration. We also highlight the limitations of the current evidence to inform a more individualized approach. Several areas for possible modifications to drug management are ripe for investigation, including: vasopressor selection and titration based on diastolic blood pressure responses; special physiologic circumstances in which sodium bicarbonate or calcium may be beneficial; and certain electrophysiologic states in shockable cardiac arrest, which may favor lidocaine or amiodarone.
Crit Care Clin
· 2026 Jan · PMID 41260709
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Effective ventilation during cardiac arrest is vital for maintaining oxygenation and gas exchange, yet both hyperventilation and hypoventilation pose significant risks, including lung injury and neurologic damage. Curren...Effective ventilation during cardiac arrest is vital for maintaining oxygenation and gas exchange, yet both hyperventilation and hypoventilation pose significant risks, including lung injury and neurologic damage. Current guidelines recommend specific ventilation volumes and rates, but evidence supporting these targets is limited, and actual practices often deviate, potentially impacting outcomes. Research challenges, such as the chaotic out-of-hospital setting, measurement inaccuracies, and patient heterogeneity, complicate the development of optimal strategies. Emerging technologies like real-time ventilation feedback devices and capnography offer promising avenues to improve ventilation quality, although their direct impact on survival and neurologic recovery remains unclear.
Crit Care Clin
· 2026 Jan · PMID 41260708
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Cardiac arrest care is a global problem, with high rates of morbidity and mortality. In resource-limited settings (RLS), survival is low for both in-hospital cardiac arrest and out-of-hospital cardiac arrest. Cardiac arr...Cardiac arrest care is a global problem, with high rates of morbidity and mortality. In resource-limited settings (RLS), survival is low for both in-hospital cardiac arrest and out-of-hospital cardiac arrest. Cardiac arrest care in RLS is limited by low rates of basic and advanced life support training, limited bystander cardiopulmonary resuscitation, nascent prehospital, emergency and critical care capacity and systems, limited human and material resources, and a paucity of data from RLS to inform guideline adaptation. Future steps to improve cardiac arrest care across the chain of survival include synergistic health systems strengthening, education, research, and legal and policy adaptations.