From Desperation to Digital Miracle: The Life-Saving Impact of Digital-ICU Technology on an Adolescent's Journey: A Case Report

Introduction

Globally, the landscape of Intensive Care Unit (ICU) care reflects a growing demand for the timely availability of super-specialized critical care expertise. Most hospitals face the challenge of 24×7 availability (especially during night hours). Therefore, a well-designed smart ICU concept addresses these challenges by providing 24 ×7 h access to super-specialized intensivists and the timely implementation of advanced medical support, thus revolutionizing critical care delivery.

The evolution of critical care medicine as a super-specialty has been a long journey. Over time, the medical world has acknowledged the importance of its diversified approach, which incorporates the potential for superior diagnosis establishment, intelligent monitoring, and timely therapeutic decisions. This approach of transferring through tele-ICU technology to the receiver end could be a game-changer. This will involve a combination of proven precision technology with expert clinical knowledge, breaking the barriers of access and cost, thereby contributing to better patient care and improved outcomes. We report a case of 16 year old male who presented to spoke-site center with massive bleeding per rectum and non-recordable BP. The patient underwent initial resuscitation under the guidance of tele-ICU team and was transferred to our center for further management.

Case report

A 16-year-old boy with no known comorbidities was admitted to the Emergency Room (ER) of a spoke site in Prayagraj, Uttar Pradesh. He presented with high-grade fever and abdominal pain for five days. The pain was periumbilical, radiating to the back, and escalating over the last three days. Two hours before presentation to the ER, he experienced an episode of massive bleeding in the rectum, followed by unconsciousness.

On presentation, he was drowsy with a Glasgow Coma Scale (GCS)—E₂V₁M₄, non-recordable Blood Pressure (BP), Heart Rate (HR) of 168/min, and feeble carotid pulse. His Arterial Blood Gas (ABG) showed severe metabolic acidosis with pH-6.90, pCO₂-16 mmHg, HCO³⁻-5.4 mmol/L, lactate = 16 mmol/L. The team at the spoke site took immediate intravenous (IV) access, started with an IV fluid bolus, and connected to the tele-ICU hub command center intensivist for management guidance. The tele-ICU hub patient was advised to continue fluid resuscitation initially with a 1000 ml normal saline (NS) bolus and to start vasopressor support with inj. Noradrenaline was infused through the external jugular vein cannula, targeting a Mean Arterial Pressure (MAP) of 65 mmHg.

Seeing the critical status of the patient, the team at the command center hub informed the family about the gravity of his critical condition, the management of which required urgent life-saving intervention. Consent was obtained for emergency procedures and urgent placement of the central venous catheter. Intubation and mechanical ventilation were performed as advised by the site team, given severe acidosis, hemodynamic collapse, and encephalopathy. Meanwhile, the team at the tele-ICU hub advised point-of-care ultrasound (POCUS)-based resuscitation, where the remote site duty doctor was asked to show the inferior vena cava (IVC) with ultrasound through high-definition cameras placed at spoke sites and guidance for fluid resuscitation was provided through real-time audio-visual communication. At a dose of 0.04 unit/min, inj. Vasopressin infusion was also administered to achieve a MAP of 65 mmHg. Simultaneously, 1 unit life-saving packed red blood cell (PRBC) transfusion was performed with continuous monitoring and guidance through a tele-ICU.

After the initial stabilization, the patient’s history was reviewed by the parents through a tele-ICU interface. The child had off-and-on abdominal pain for two months, which gradually increased in intensity and was associated with high-grade fever. For this, they underwent an outpatient department (OPD)-based consultation 4 days prior and were advised oral antibiotics and an ultrasound of the abdomen. As per the father, the patient developed bleeding per rectum in the evening just after the abdominal ultrasound was performed (the report was awaited), and he was rushed to the nearest hospital, where our tele-ICU services are already functional. Clinical history was suspicious for underlying chronic pathology; therefore, parents were counselled about the need for further workup and possible gastroenterological interventions, for which referral to a tertiary care center was advised. Subsequently, fluid resuscitation was continued with maintenance fluid at a rate of 150 ml/hr, guided by dynamic IVC parameters and serum lactate levels.

Ultrasonography performed the same evening showed portal venous thrombosis, which raised suspicion of underlying ischemic necrosis leading to bleeding in the rectum. Therefore, once the blood pressure stabilizes, the vasopressor with inj. noradrenaline dose of 0.21 mcg/kg/min, and inj. vasopressin at 0.04 units/min, HR settled to a range of 110–130/min, and with improving ABG parameters (pH = 7.30, pCO₂ = 30 mmHg, HCO³⁻ = 10 mmol/L, lactate = 5.8 mmol/L). The family was advised to transport the patient to a higher center for further evaluation and management of gastrointestinal bleeding.

Transportation was also performed under the continuous guidance of the tele-ICU Command Center doctors’ team, who took care of ongoing resuscitation and titrating vasopressors, thus maintaining the vital signs en route to the higher center hospital. Around midnight, the ambulance reached the hospital, where the ER team was already fully apprised of the patient’s history and management and was ready to receive the patient for advanced medical care. All required super-specialist teams–Critical Care Medicine experts, gastroenterologists, gastrosurgeons, and interventional radiologists–were informed before arrival. After initial blood workup and stabilization with a relatively improved blood gas trend, the patient was slated for Computed Tomography (CT) angiography of the abdomen, which revealed portal vein thrombosis involving the main portal vein as well as the right and left branches; no active bleeding was noted, but there were changes in early bowel ischemia (Figure 1(A), 1(B)). The patient was started on conservative medical management with therapeutic anticoagulation along with mechanical ventilation and resuscitation.

However, the thrombosis continued to increase, and a repeat scan after 10 days suggested veno-occlusive mesenteric ischemia with impending gangrene in the jejunum, indicating the need for surgical intervention. The patient underwent surgical resection of the jejunum with part of the ileum, an end jejunostomy, and a distal mucous fistula. Complicated intra-abdominal infection with multidrug-resistant (MDR) Pseudomonas was also diagnosed and treated with high-dose antibiotics. The patient was gradually weaned from the ventilator. However, he still required continued intensive care with intravenous antibiotics, anticoagulants, special feeding (i.e., oral diet and bile refeeding via a distal mucous fistula), and active physiotherapy.

The patient was discharged after an ICU stay of 26 days to the same spoke site hospital, where IV antimicrobials, rehabilitation, nutritional support, and recovery were performed under continuous monitoring by the tele-ICU command center intensivist and gastro-surgery team (Figure 2).

The patient eventually experienced a satisfactory recovery and was discharged. He was able to make this out only because of management during those “CRITICAL GOLDEN HOURS” with the help of this Digital-Medical critical care setup, which provided life-saving clinical expertise within the critical time frame.

Discussion

Concerning clinical expertise, suboptimal ICU care is mainly due to the non-availability of super-specialized ICU experts 24 × 7 worldwide. This lack of access to available medical resources has deprived a large proportion of patients of the benefits of optimal super specialized critical care services. Therefore, many centers have adopted tele-ICU technology to optimize ICU functioning, with continuous support from command-center teams. In India, where the doctor-to-patient ratio is already substandard as per WHO recommendations, critical care resources are meagre, with an estimated 5000–13,000 trained intensivists nationwide [1]. Bridging these gaps may not readily be accomplished through the creation of more training opportunities in the short term, considering the costs and long time needed to train a critical care super-specialist. Novel low-cost solutions that optimize existing resources and enable a limited number of specialists to deliver care to more people are urgently required. By increasing the number of available care providers, albeit remotely, ICU telemedicine is one tool that enables expert ICU command centers to provide quality critical care in remote settings and ensures that care remains timely, comprehensive, and accurate.

The American Telemedicine Association defines tele-ICU as “a network of audio-visual communication and computer systems that provide the foundation for a collaborative, inter-professional care model focusing on critically ill patients” [2]. ICU telemedicine was first reported in 1977 when an intensivist at a university hospital remotely conducted daily rounds and once-weekly teaching conferences with staff of a small non-academic ICU via a two-way audio-visual link [3]. Through their ground-breaking experience, it was concluded that ICU telemedicine though expensive, was feasible, generally acceptable to both patients and ICU staff and had great potential to improve patient care, provide education, and facilitate the establishment of multihospital networks. Since then, tele-ICU technology has evolved to the level of machine-to-machine integration to minimize delays in patient information transfer, thereby breaking geographical barriers. Several studies have evaluated the role of technical care in patient outcomes. However, reviews of the existing literature demonstrate mixed effects of telemedicine ICU on patient outcomes, owing to uneven methodologies, outcome variables, and measures. A large multicentre observational study reported that four individual components of the intervention were associated with better outcomes, including prompt remote intensivist case review, improved adherence to evidence-based practices, reduced response times to alarms, and real-time use of performance measures [4].

Several systematic reviews and meta-analyses based on these mostly uncontrolled, before–after observational studies concluded that tele-ICU is significantly associated with reduced ICU mortality and Length Of Stay (LOS), with variable results for hospital mortality and LOS [5, 6]. Overall, these data suggest that tele-ICU may improve patient outcomes when applied in the appropriate settings.

Technology has emerged as a game-changer, saving the life of this young boy through timely decisions during the golden hours of haemorrhagic shock, where guided resuscitation is of prime importance. Fortunately, he presented to a center equipped with a tele-ICU facility, enabling the hospital staff to manage emergency resuscitation and execute timely treatment in the late evening hours. This timely treatment and intervention led to a win in the battle against vascular thrombotic disease, gastrointestinal bleeding, sepsis, and multi-organ dysfunction syndrome.

Many cases collapsed either before or while reaching an appropriate health facility in the absence of timely treatment and interventions. Delays in addressing critical conditions are a major contributor to mortality and morbidity in these patients. A good healthcare system for ICU patients requires an ICU infrastructure, availability of all life-saving facilities, and execution of trained nurses and doctor manpower. Worldwide, the availability of an ICU specialist who understands the medical sciences behind these severe diseases is the most difficult to manage.

Suggested strategies to maximize the potential benefit of tele-ICU include ensuring adequate autonomy of the tele-ICU team and building integrated teams between remote providers and bedside clinicians with practical training for staff on the ground. Promote active co-management with direct intervention by the tele-ICU team, financial feasibility, adaptability to the local context, scalability, development of telemedicine-based protocols for care processes and quality improvement, and incorporation of internal benchmarking practices led by telemedicine team [7, 8].

The case highlights the life-saving impact of timely intervention of super—specialized critical care team through tele—ICU. However, further research is needed using mixed-methods approaches and validated models to evaluate public health interventions and understand how, when, and where tele-ICUs should be implemented. The organizational structure of tele-ICU programs and staffing models are yet to be defined, such as the optimal ratio of off-site providers to patients, their core competencies, and the optimal ratio of on-site healthcare providers to patients in spoke-site ICU.

Conclusions

The tele-ICU represents an organizational innovation and a promising mechanism that has the potential to improve access to and quality of critical care in remote settings. More insights are required to gain a deeper understanding of how to maximize the value and effectiveness of this technology.

Authors’ contribution

Bano, Noor: Conceptualization, Data Curation, Investigation, Methodology, Resources, Supervision, Validation, Writing (Draft Preparation), Approved the final version; Dubey, Dilip: Conceptualization, Data Curation, Investigation, Methodology, Resources, Supervision, Validation, Writing (Draft Preparation), Writing (Review and Editing), Approved the final version; Paul, Subhankar: Investigation, Methodology, Resources, Approved the final version; Kulshrestha, Vidushi: Investigation, Methodology, Resources, Supervision, Validation, Writing (Draft Preparation), Approved the final version; Shukla, Ashish: Investigation, Methodology, Resources, Approved the final version; Kumar, Vijit: Investigation, Methodology, Resources, Approved the final version; Prakash, Vipul: Data Curation, Methodology, Resources, Approved the final version; Sangwan, Pushpender: Investigation, Methodology, Approved the final version; Verma, Sandeep: Investigation, Methodology, Resources, Approved the final version; Malviya, Nishant: Investigation, Methodology, Resources, Approved the final version; Kumar, Alok: Investigation, Methodology, Resources, Approved the final version; Dubey, Madhulika: Conceptualization, Supervision, Validation, Writing (Draft Preparation), Writing (Review and Editing), Approved the final version; James, Aksa: Writing (Draft Preparation), Approved the final version; Purnima, Aanjan: Investigation, Methodology, Resources, Approved the final version; Srivastava, Shashwat: Investigation, Methodology, Resources, Approved the final version; Shah, Tajamul H.: Supervision, Validation, Writing (Draft Preparation), Writing (Review and Editing), Approved the final version; Gupta, Anshul: Investigation, Approved the final version; Ravichandran, Deepak: Investigation, Approved the final version; Ali, Mohammad: Investigations, Approved the final version;

Funding

This research did not receive external funding from any agencies.

Ethical statement

Not Applicable.

Data availability statement

Source data is not available for this article.

Conflict of interest

The authors declare no conflict of interest.