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 is necessary to address the challenges in providing 24 ×7 h access to super-specialized intensivists, the timely implementation of advanced medical support and revolutionizing critical care delivery.

The evolution of critical care medicine as a super-specialty has been a long journey. Over time, the medical ecosystem has acknowledged the importance of its diversified approach, which incorporates the potential for superior care establishment, intelligent monitoring, and timely therapeutic decisions. This approach of transferring healthcare through tele-ICU technology to the end consumer is a game-changer. This involves 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 a 16-year-old male who presented to spoke site with massive rectal bleeding and non-recordable blood pressure (BP). The patient underwent initial resuscitation under the guidance of tele-ICU team and was transferred to the tertiary center for further management.

Case report

A 16-year-old male with no known health issues 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 the preceding five days. The pain was periumbilical, radiating to the back, and escalated over the last three days. Two hours before presentation to the ER, he experienced an episode of massive bleeding from the rectum, followed by unconsciousness.

On examination, he was drowsy with a GCS (Glasgow Coma Scale) score of E₂V₁M₄, non-recordable BP, Heart Rate (HR) of 168/min, and feeble carotid pulse. Arterial Blood Gas (ABG) analysis showed severe metabolic acidosis with pH-6.90, pCO₂-16 mmHg, HCO³⁻-5.4 mmol/L, and lactate = 16 mmol/L. The spoke site team immediately established intravenous (IV) access, started a 1000 ml normal saline (NS) bolus, and connected to the tele-ICU hub command center intensivist for the next steps. The tele-ICU hub was advised to continue fluid resuscitation and start vasopressor support with inj. noradrenaline as an infusion through the external jugular vein cannula, targeting a Mean Arterial Pressure (MAP) of 65 mm Hg.

The command center hub informed the family about the gravity of the adolescent’s critical condition and the care plan 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 due to severe acidosis, hemodynamic collapse, and encephalopathy. Meanwhile, the team at the tele-ICU hub recommended point-of- care ultrasound (POCUS)-based resuscitation, where the remote site duty physician imaged the inferior vena cava (IVC) with ultrasound through high-definition cameras placed at spoke sites and to guide fluid resuscitation through real-time audio-visual communication. At 0.04 unit/min, inj. vasopressin was infused to achieve a MAP of 65 mm Hg. Simultaneously, 1 unit of packed red blood cell (PRBC) transfusion was performed with continuous monitoring and guidance through tele-ICU.

After initial stabilization, the patient’s detailed medical history was elicited from the parents through tele-ICU. The adolescent had intermittent abdominal pain for two months, which gradually increased in intensity and was associated with high-grade fever. In this regard, an outpatient department (OPD)-based consultation was done 4 days prior to the critical incident and were advised oral antibiotics and an ultrasound of the abdomen. As per the father, on the day of the critical incident, the patient developed rectal bleeding 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 were deployed and functional. Clinical history was insignificant 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 revealed portal venous thrombosis and indicated the possibility of underlying ischemic necrosis leading to rectal bleeding. Therefore, 0.21 mcg/kg/min of inj. noradrenaline and 0.04 units/min of inj. vasopressin was administered for stabilization of BP, thereafter, HR settled to a range of 110–130/min, and ABG parameters improved (pH = 7.30, pCO₂ = 30 mmHg, HCO³⁻ = 10 mmol/L, lactate = 5.8 mmol/L). The family was advised to shift the patient to a tertiary care center for further evaluation and management of gastrointestinal bleeding.

The adolescent was transferred under the continuous guidance of the tele-ICU Command Center doctors’ team, which monitored the resuscitation protocol and the vital signs en route to the tertiary care center. Around midnight, the ambulance reached the hospital, where the ER team, fully apprised of the patient’s history and management, was ready to take over. The required super-specialist team members–Critical Care Medicine experts, gastroenterologists, gastrosurgeons, and interventional radiologists–were kept informed. After initial blood workup, which revealed a relatively improved ABG trend, the patient was slated for Computed Tomography (CT) angiography of the abdomen. Portal vein thrombosis involving the main portal vein as well as the right and left branches was confirmed; no active bleeding was noted, but there were changes suggestive of early bowel ischemia (Figure 1(A), 1(B)). Conservative medical management was resumed along with therapeutic anticoagulation, mechanical ventilation and resuscitation.

However, the thrombosis persisted 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. Intra-abdominal infection with multidrug-resistant (MDR) Pseudomonas was also diagnosed and was 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 accomplished 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. His miraculous recovery was mainly due to the management during the “CRITICAL GOLDEN HOURS” with the help of Digital-Medical critical care setup, which provided life-saving clinical expertise within the critical time frame.

Discussion

Worldwide, suboptimal ICU care is mainly attributed to the non-availability of super-specialized ICU experts 24 × 7. 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 (based on WHO recommendations), critical care resources are meager, 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 the duration 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 a tool that enables expert ICU command centers to provide quality critical care in remote settings and ensures that care provided is 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 a small non-academic ICU staff via a two-way audio-visual link [3]. Through their ground-breaking experience, it was determined 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, literature review reveals mixed effects of telemedicine ICU on patient outcomes, owing to uneven methodologies, outcome variables, and measures. A large multicentre observational study reported that prompt remote intensivist case review, improved adherence to evidence-based practices, reduced response times to alarms, and real-time use of performance measures were associated with better outcomes [4].

Several systematic reviews and meta-analyses based mostly on uncontrolled and 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, data suggest that tele-ICU improves patient outcomes when applied in the appropriate settings.

Technology emerged as a game-changer, saving the life of this adolescent through timely decisions, during the critical golden hours, of haemorrhagic shock management, 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 victory in the battle against vascular thrombotic disease, gastrointestinal bleeding, sepsis, and multi-organ dysfunction syndrome.

Many patients have collapsed either before or while reaching an appropriate health facility in the absence of timely treatment and interventions. Delay in addressing critical conditions are a major contributor to mortality and morbidity of these patients. A good healthcare system catering to ICU patients requires a robust infrastructure with the necessary life-saving equipment, and availability of trained healthcare professionals. Worldwide, the availability of an ICU specialist who understands the medical sciences behind these severe diseases is the most difficult to source.

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. Promoting 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 along with quality improvement, and incorporation of internal benchmarking practices led by telemedicine team can change the future landscape of healthcare [7, 8].

The case report 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 determine 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 a healthcare innovation at organization level and a promising workflow with potential to improve access and quality of critical care in remote settings. Additional insights are needed for deeper understanding of the way forward to maximize the value and effectiveness of this technology at scale. 

Authors’ contribution

Bano, Noor: Conceptualization, Data curation, Investigation, Methodology, Resources, Supervision, Validation, Writing – original draft; Dubey, Dilip: Conceptualization, Data curation, Investigation, Methodology, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing; Paul, Subhankar: Investigation, Methodology, Resources; Kulshrestha, Vidushi: Investigation, Methodology, Resources, Supervision, Validation, Writing – original draft; Shukla, Ashish: Investigation, Methodology, Resources; Kumar, Vijit: Investigation, Methodology, Resources; Prakash, Vipul: Data curation, Methodology, Resources; Sangwan, Pushpender: Investigation, Methodology; Verma, Sandeep: Investigation, Methodology, Resources; Malviya, Nishant: Investigation, Methodology, Resources; Kumar, Alok: Investigation, Methodology, Resources; Dubey, Madhulika: Conceptualization, Supervision, Validation, Writing – original draft, Writing – review & editing; James, Aksa: Writing – original draft; Purnima, Aanjan: Investigation, Methodology, Resources; Srivastava, Shashwat: Investigation, Methodology, Resources; Shah, Tajamul H.: Supervision, Validation, Writing – original draft, Writing – review & editing; Gupta, Anshul: Investigation; Ravichandran, Deepak: Investigation; Ali, Mohammad: Investigation. 

Funding

This research did not receive external funding from any agencies. 

Ethical statement

The patient provided written informed consent for the publication of their image, and all identifying information has been anonymized to the greatest extent possible. 

Data availability statement

Source data is not available for this article. 

Conflict of interest

The authors declare no conflict of interest.