Date post: | 02-Jun-2015 |
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Clinical Decision Support System (CDSS) Sample Scenario
© 2011 J. Zaleski
State of Acute Care• American College of Physicians estimates 500,000 deaths
annually in ICUs (U.S.)• Key Drivers
Patient safety Longitudinal EMR deployment Increase efficiency Staffing shortages Increasing numbers of CC beds
• Larger amounts of hemodynamic, respiratory, I&O information will be automated Motivates enterprise integration Reduces charting workload Improves completeness, accuracy
Types of Data Most Used in ICU Clinical Decision Making
Data Type Value
Monitors and monitoring 13%
Observations 21%
Laboratory 33%
Drugs, I&O, IV 22%
Blood gas 9%
Other 2%
Source: E.H. Shortliffe and J.J. Cimino, Biomedical Informatics Computer Applications in Health Care and Biomedicine, page 605.
CDSS Sample Case:When to discontinue post-operative mechanical ventilation
• Discontinuation from mechanical ventilation a key activity in surgical intensive care unit (SICU), yet, no guarantees as to outcomes:– When to begin spontaneous breathing trials?– When is patient viable to be extubated?
• Discontinue as quickly as possible– Longer time on ventilator higher likelihood of adverse events
• Ventilator acquired pneumonia• Respiratory distress
– Can exacerbate co-morbidities– Cost
• Candidate patients: Coronary artery bypass grafting (CABG)– Fairly common procedure– Technologically-dependent patients
Devices Supporting Acute Care Environment
MechanicalVentilation
InfusionBed
Monitors
Intra-Aortic
BalloonPumps
Anesthesia
Highly Technologically-Dependent Patients
Case Study: CABG Patient
PatientArrives in
ORInduction
Source: J. Zaleski
On Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Case Study: CABG Patient
Time In: 7:15 Induction: Isoflurane Pt Ht: 157 cm
CABG x 3 40 CCs fentanyl (15 mg/kg) BSA: 1.7 m^215 mg
Pancuronium
Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl mgpancuronium
mglopressor Notes
7:15 76 121/64 98 7 0.5
7:30 83 117/66 99 4.37:40 57 93/52 1007:45 66 100/55 100 300 78:00 61 95/57 100 Swan in place
8:05 62 101/60 100 34.38:10 64 97/58 100 34.4 34.98:25 86 132/78 100 34.3 34.7 298:30 116 116/76 99 34.3 35.2 278:35 98 116/75 99 34.2 35 298:40 92 112/74 100 34.1 34.9 298:45 100 113/70 99 34.1 34.8 298:50 96 112/71 99 34 34.7 299:00 91 97/62 99 34 34.7 319:05 97 109/70 100 33.9 34.5 309:20 93 114/68 100 33.8 34.4 319:30 103 95/61 100 33.7 34.2 32
ContinuousMonitoring
Meds & Drips
Source: J. Zaleski
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Case Study: CABG Patient
Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl mgpancuronium
mglopressor Notes
9:35 94 93/60 100 33.6 34.2 30Canula placed-
rt. atria; bypassing heart
9:40 94 103/65 100 33.6 34.1 369:45 94 112/67 100 33.6 34.1 36 3 mg (up)9:50 94 113/68 100 33.6 34 339:55 95 103/69 100 33.6 33.9 29
10:00 99 101/68 100 33.6 33.9 28 12 0.48Fibrillation.
Cross-Clamp
10:07 20.8K injection
commenced
10:08 1610:09 12
10:11 10K injection complete
10:15 33 32.510:20 32.8 32.7
10:30 32.9 33Myocard temp:
14
10:35 33.1 3310:45 33 33
10:50 33.3 33.4 Begin re-warm
Core
tem
pera
ture
redu
ction
Heart stoppage
Source: J. Zaleski
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Case Study: CABG Patient
Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core T blad ETCO2 RR Vt fentanyl mgpancuronium
mglopressor Notes
10:55 33.8 33.7 5 mg (up)
11:00 34.9 34.9250 mics
(up)2 mg (up)
11:05 35.4 35.311:10 35.9 35.411:15 36 35.5 Restart / Defib
11:16 36.2 35.911:17 90 79/65 36.3 3611:20 77 107/58 100 4.18 36.2 36 24 Off Bypass
11:25 79 103/56 100 35.9 35.9 2511:30 88 103/52 100 35.5 35.911:35 89 106/55 100 35.4 35.7 2611:40 96 108/61 100 35.2 35.6 2411:45 93 115/64 100 35.1 35.5 2511:50 93 96/53 100 34.9 35.3 2311:55 96 112/65 100 34.8 35.1 2512:00 108 104/62 100 34.7 35 2412:05 105 107/66 100 34.7 34.8 2412:10 88 103/63 100 34.6 34.4 23 2.5 mg12:15 87 99/60 100 34.6 34.912:20 88 121/73 100 34.8 24 Move to SICU
Heart restart
Source: J. Zaleski
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Case Study: CABG Patient
Time HR (bpm) ABP (s/d) O2Sat CO (L/m) T Core CVP PAP
12:40 100 99/62 99 5.4 34.8 6 23/10
13:15 99 99/59 100 4.48 35.3 7 24/1413:45 104 115/63 100 5.18 35.7 10 26/1514:15 101 102/54 98 5.18 36.3 9 25/1214:40 98 108/53 100 5.2 36.6 18 31/1414:50 105 128/62 99 5.2 36.6 20 39/1614:55 104 128/62 100 5.2 36.7 19 35/1815:00 101 128/63 100 5.2 36.7 16 35/1715:25 102 110/58 100 5.2 36.7 18 28/1315:50 103 107/57 100 5.2 37 32 28/1516:45 100 107/59 100 5.2 37.1 13 30/1517:00 104 98/56 98 5.2 37.2 13 40/2117:20 103 97/56 97 5.2 37.3 13 32/1817:40 100 98/57 98 5.2 37.3 12 29/1617:45 102 94/54 98 5.2 37.3 12 31/1819:05 104 97/58 97 5.2 37.3 13 30/1820:15 106 99/59 97 5.2 37.5 11 31/1621:15 101 101/60 98 4.8 37.6 15 33/1922:35 Extubated: Vc 1.2 liters
NIF -25 cmH2O
Source: J. Zaleski
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Initial blood gas obtained upon patient arrival• Time: 12:45• pH = 7.44• PCO2 = 31 mmHg• PO2 = 100 mmHg
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Patient initially supported by mechanical ventilator on synchronous intermittent mandatory ventilation (SIMV) mode of 12 breaths per minute, tidal volume of 0.85 liters, PEEP of 5 cmH2O
• Patient spontaneous breathing is absent upon arrival due to the anesthesia and paralytic drugs administered during surgery
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Second blood gas obtained• Time: 14:00• pH = 7.41• PCO2 = 29 mmHg• PO2 = 202 mmHg
• Decision made to reduce ventilatory support
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Support reduced to 8 br/min
• Some spontaneous breathing. Clinicians choose to evaluate and await re-warming and third blood gas before attempting spontaneous breathing trial
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Third blood gas obtained• Time: 16:35• pH = 7.40• PCO2 = 37 mmHg• PO2 = 183 mmHg
• Re-warming complete• Decision made to reduce to CPAP in
preparation for spontaneous breathing trials
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Respirations, Rapid-Shallow Breathing Index normal
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Key Parameters Used to Determine Viability for Extubation
Parameter Threshold Value/Range Our PatientVital Capacity, Vc > 10mL/kg
Positive End-Expiratory Pressure, PEEP
5 cm H2O
Negative Inspiratory Force, NIF -20 cm H2O
Inspired Oxygen Fraction, FiO2 < 0.6
Spontaneous Tidal Volume, Vt > 5 mL/kg
Spontaneous Respirations 8 < Rresp < 30
Blood Alkalinity/Acidity 7.32 < pH < 7.48
Partial Pressure of Oxygen, PO2 > 80 mmHg
Partial Pressure of Carbon Dioxide, PCO2
30 mmHg < PCO2 < 50 mmHg
Normal Body Temperature, Tcore ~37 C
Ventilation Mode CPAP
Value Thresholds,Vpthi
Parameters,Pi
Patient Values,Vpti
Key Parameters Used to Determine Viability for Extubation
Parameter Threshold Value/Range Our PatientVital Capacity, Vc > 10mL/kg
Positive End-Expiratory Pressure, PEEP
5 cm H2O
Negative Inspiratory Force, NIF -20 cm H2O
Inspired Oxygen Fraction, FiO2 < 0.6
Spontaneous Tidal Volume, Vt > 5 mL/kg
Spontaneous Respirations 8 < Rresp < 30
Blood Alkalinity/Acidity 7.32 < pH < 7.48
Partial Pressure of Oxygen, PO2 > 80 mmHg
Partial Pressure of Carbon Dioxide, PCO2
30 mmHg < PCO2 < 50 mmHg
Normal Body Temperature, Tcore ~37 C
Ventilation Mode CPAP
Clinical Decision Support Systems
Key Parameters Used to Determine Extubation Viability
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
• Respirations, Rapid Shallow Breathing Index normal
• Vital capacity & NIF test performed and in normal range
• Vc = 1.2 liters• NIF = -24 cmH2O
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Case Study: CABG Patient
Source: J. Zaleski
12:44:1813:51:1014:30:1115:09:1015:48:1016:27:0917:06:0917:45:0918:24:0819:03:0819:42:0720:21:0721:00:0721:39:060
5
10
15
20
25
30
35
40
45
RRm (/min)
RRsp (/min)
Updated real-time knowledge of patient data could have led to earlier extubation
PatientArrives in
ORInduction On
Bypass
Restart Heart /
Off Bypass
Transfer to SICU
Monitoring & Management
Determine Viability
for Weaning
Extubate
Resp
irato
ry R
ate
(br/
min
)
Key Parameters Used to Determine Viability for Extubation
Parameter Threshold Value/Range Our PatientVital Capacity, Vc > 10mL/kg 1.2L (70 kg)
Positive End-Expiratory Pressure, PEEP
5 cm H2O 5 cm H2O
Negative Inspiratory Force, NIF -20 cm H2O -24 cm H2O
Inspired Oxygen Fraction, FiO2 < 0.6 0.35
Spontaneous Tidal Volume, Vt > 5 mL/kg 0.55L (70 kg)
Spontaneous Respirations 8 < Rresp < 30 ~20
Blood Alkalinity/Acidity 7.32 < pH < 7.48 7.4
Partial Pressure of Oxygen, PO2 > 80 mmHg 183 mmHg
Partial Pressure of Carbon Dioxide, PCO2
30 mmHg < PCO2 < 50 mmHg 37 mmHg
Normal Body Temperature, Tcore ~37 C ~37 C
Ventilation Mode CPAP CPAP
Data suggest attempts at spontaneous breathing trials could begin much sooner than actually occurred
Workflow Considerations• Data show patient meets extubation criteria many hours before
actual extubation– Indicates clear benefit of utilizing these data for patient care– Simple reminders to staff can achieve great benefits for patient
• Notification of readiness to wean important for clinical workflow, patient care management– Is patient viable or is it too early?– Any co-morbidities that can influence the outcome?– All necessary staff so informed and aligned on plans?
• Notification as to life-threatening events requires up-to-date and accurate information– Hemodynamic instabilities/Shock– Respiratory distress
THANK YOU!