Upcoming and urgent challenges in critical care research based on COVID-19 pandemic experience.

While the coronavirus disease 2019 (COVID-19) pandemic placed a heavy burden on healthcare systems worldwide, it also induced urgent mobilisation of research teams to develop treatments preventing or curing the disease and its consequences. It has, therefore, challenged critical care research to rapidly focus on specific fields while forcing critical care physicians to make difficult ethical decisions. This narrative review aims to summarise critical care research -from organisation to research fields- in this pandemic setting and to highlight opportunities to improve research efficiency in the future, based on what is learned from COVID-19. This pressure on research revealed, i.e., (i) the need to harmonise regulatory processes between countries, allowing simplified organisation of international research networks to improve their efficiency in answering large-scale questions; (ii) the importance of developing translational research from which therapeutic innovations can emerge; (iii) the need for improved triage and predictive scores to rationalise admission to the intensive care unit. In this context, key areas for future critical care research and better pandemic preparedness are artificial intelligence applied to healthcare, characterisation of long-term symptoms, and ethical considerations. Such collaborative research efforts should involve groups from both high and low-to-middle income countries to propose worldwide solutions. As a conclusion, stress tests on healthcare organisations should be viewed as opportunities to design new research frameworks and strategies. Worldwide availability of research networks ready to operate is essential to be prepared for next pandemics. Importantly, researchers and physicians should prioritise realistic and ethical goals for both clinical care and research.

Florbetapir-PET ß-amyloid imaging and associated neuropsychological trajectories in survivors of critical illness: A case series.

PURPOSE: Cognitive impairment resembling Alzheimer's disease is common in survivors of critical illness. We hypothesized that Intensive Care Unit (ICU) survivors with cognitive impairment would have significant amyloid and designed a pilot study to explore this relationship. MATERIALS AND METHODS: A pilot, case series of a convenience sample of 14 adult medical and surgical ICU survivors, in a clinical neuroradiology clinic. Patients underwent cognitive testing at 3months, 1year, 4years, and 6years after hospital discharge with the Repeatable Battery for the Assessment of Neuropsychological Status. They received a single PET scan using amyloid PET imaging (florbetapir F18) 2 to 4years after their ICU stay. RESULTS: Amyloid (defined as a Standard Uptake Value ratio or SUVr >1.10) was present in 2 of 14 (14%) individuals, both of whom demonstrated significant cognitive impairment yet no consistent decline over time. Of the 6 impaired patients (RBANS<78), 4 (66.7%) were amyloid negative. CONCLUSIONS: It is feasible to assess ICU survivors with amyloid imaging. In this small sample, most patients with cognitive impairment were negative on amyloid PET imaging, which raises the possibility that ICU survivors may experience a unique form of dementia not driven by an amyloid related mechanism.

Tools to detect delirium superimposed on dementia: a systematic review.

OBJECTIVES: To identify valid tools to diagnose delirium superimposed on dementia. DESIGN: Systematic review of studies of delirium tools that explicitly included individuals with dementia. SETTING: Hospital. PARTICIPANTS: Studies were included if delirium assessment tools were validated against standard criteria, and the presence of dementia was assessed according to standard criteria that used validated instruments. MEASUREMENTS: PubMed, Embase, and Web of Science databases were searched for articles in English published between January 1960 and January 2012. RESULTS: Nine studies fulfilled the selection criteria. Of 1,569 participants, 401 had dementia, and 50 had delirium superimposed on dementia. Six delirium tools were evaluated. One study using the Confusion Assessment Method (CAM) with 85% of participants with dementia had high specificity (96-100%) and moderate sensitivity (77%). Two intensive care unit studies that used the CAM for the Intensive Care Unit (CAM-ICU) reported 100% sensitivity and specificity for delirium in 23 individuals with dementia. One study using electroencephalography reported sensitivity of 67% and specificity of 91% in a population with a 100% prevalence of dementia. No studies examined potential effects of dementia severity or subtype on diagnostic accuracy. CONCLUSIONS: The evidence base on tools for detection of delirium superimposed on dementia is limited, although some existing tools show promise. Further studies of existing or refined tools with larger samples and more-detailed characterization of dementia are required to address the identification of delirium superimposed on dementia.

[Spanish version of the CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). Pilot study of validation]. / Versión en español del método para la evaluación de la confusión en cuidados intensivos, estudio piloto de validación.

OBJECTIVE: To validate the Spanish version of the CAM-ICU. DESIGN: Validation study. The inter-rater reliability and validity were evaluated using a blind comparison with the DSM-IVTR criteria (reference standard) in a group of patients hospitalized in an Intensive Care Unit (ICU). SETTING: Medical-surgical ICU. PATIENTS: 129 adults with RASS >-4 score, within the 24-48 h of ICU admission. Independent application of the CAM-ICU by two intensive care specialists and evaluation by a psychiatrist using the DSM-IVTR criteria for delirium. RESULTS: Prevalence of delirium in the sample was 26.4%, this being and 48.3% in the 29 patients who received mechanical ventilation. Inter-rater reliability in the whole sample according to the Kappa index was 0.792 (95% CI 0.662-0.922, p<0.001) and in those who received mechanical ventilation was 0.726 (95% CI 0.487-0.965, p<0.001). The sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were 79.4% (95% CI 63.2-89.7%); 97.9% (95% CI 92.6-99.4%); 93.1% (95% CI 78.0-98.1%); 93.0% (95% CI 86.3-96.6%); 37.72 (95% CI 9.47-150.20) and 0.21(95% CI 0.11-0.41), respectively, in the whole sample. In mechanically-ventilated patients, sensitivity, specificity, PPV, NPV, +LR and -LR were 92.9% (95% CI 68.5-98.7%); 86.7% (95% CI 62.1-96.3%); 86.7% (95% CI 62.1-96.3%); 92.9% (95% CI 68.5-98.7%); 6.96(95% CI 1.90-25.51) and 0.08 (95% CI 0.01-0.55), respectively. CONCLUSION: The Spanish version of the CAM-ICU is reliable. Its sensitivity, specificity and predictive values should be considered good.

[Confusion Assessment Method for diagnosing delirium in ICU patients (CAM-ICU): cultural adaptation and validation of the Spanish version]. / Método para la evaluación de la confusión en la unidad de cuidados intensivos para el diagnóstico de delírium: adaptación cultural y validación de la versión en idioma español.

OBJECTIVE: To adapt the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium to the language and culture of Spain and to validate the adapted version. DESIGN: Population validation. SETTING: Intensive care units in a 600-bed university hospital. PATIENTS: We studied 29 critical patients undergoing mechanical ventilation. Mean age was 70 years (range 58-77 years), mean APACHE II score 16 (range 13-21), and mean SOFA score 7 (range 4-8). INTERVENTION: Two independent operators applied the Spanish version of the CAM-ICU and a psychiatrist applied the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Revised (DSM IV TR). MAIN OUTCOME VARIABLES: Concordance (kappa index), internal consistency (Cronbach's alpha), and validity (sensitivity and specificity) of the Spanish version of the CAM-ICU were compared to the DSM IV TR, which is considered the current gold standard. RESULTS: The translation and cultural adaptation was carried out in accordance with current international guidelines. A total of 65 assessments were performed in 29 patients. The interobserver concordance was high: kappa statistic 0.91 (95% CI: 0.86-0.96). The internal consistence was adequate: Cronbach's alpha=0.84 (unilateral 95% CI: 0.77). For observer A (a physician), the sensitivity of the Spanish version of the CAM-ICU was 80% and the specificity was 96%. For observer B, (a nurse) the sensitivity was 83% and the specificity was 96%. CONCLUSIONS: The Spanish version of the CAM-ICU is a valid, reliable, and reproducible instrument that can be satisfactorily applied to diagnose delirium in Spanish-speaking ICU patients.