Neuromodulation, through various forms of invasive and noninvasive stimulations at the central or peripheral level, can enhance or suppress neural activities, offering the potential for therapeutic intervention. Studies of neuromodulation have reported intriguing clinical outcomes and promising application prospects across various disciplines, particularly in the realm of novel therapeutic modalities. Critically ill patients are commonly susceptible to intractable systematic dysfunctions due to sedation, immobility, and controlled ventilation. In recent years, the application of neuromodulation in the intensive care unit (ICU) has increased, and its efficacy has been tested in multiple scenarios across critical stages of the disease process.
Key Points
- Definition and Scope: Neuromodulation involves stimulating the nervous system at central or peripheral levels to enhance or suppress neural activities, applicable in critical illnesses.
- Critical Illness Polyneuromyopathy (CIPNM): Transcutaneous electrical muscle stimulation (TEMS) preserves muscle strength and reduces ventilation duration in ICU patients. Evidence is mixed, with some systematic reviews citing low-quality data and the need for more robust trials.
- Diaphragmatic Dysfunction: Transcutaneous electrical diaphragmatic stimulation (TEDS) improves respiratory muscle strength and reduces dysfunction during mechanical ventilation. Limited studies show inconsistent outcomes, requiring further research.
- Refractory Status Epilepticus: Vagal nerve stimulation (VNS) has interrupted refractory seizures in 74% of cases in systematic reviews. Acute implantation shows promise, but cost-effectiveness and large-scale validation are needed.
- Coma and Disorders of Consciousness: Transcutaneous VNS (tVNS) and right median nerve stimulation (RMNS) improve consciousness and neurological outcomes. Mechanisms include enhanced synaptic activity, increased perfusion, and neurotrophic factor release.
- Anti-Inflammatory Effects: tVNS has shown potential in reducing serum cytokines in sepsis, demonstrating systemic benefits beyond neurological conditions.
- Safety and Limitations: Risks include local skin effects, interference with pacemakers, and contraindications in specific conditions. Practical challenges include patient tolerance, device integration, and treatment standardization.
- Preclinical and Emerging Evidence: Mechanistic studies indicate neuromodulation’s potential for broader applications in stabilizing vital signs and reducing stress responses in the ICU.
- Current Evidence Gaps: Scarcity of high-quality randomized trials limits widespread adoption and guideline development.
- Future Directions: Multicenter trials and innovative technologies, such as advanced stimulators, are crucial for validating neuromodulation’s therapeutic role in critical care.
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