Intelligent Decision Support Systems in Ventilation Management

Introduction: Intensive Care Unit (ICU) medical personnel, in an ongoing process termed ventilation management, utilize patient physiology and pathology data to define ventilator apparatus settings. Aims: The aim of the research is to develop and evaluate in comparison hybrid ventilation advisor systems, that could support ventilation management process, specific to lung pathology for patients ventilated in control mode. Methodology: A questionnaire was designed and circulated to Intensivists. Patient data, as defined by the questionnaire analysis, were collected and categorized into three lung pathologies. Three ICU doctors evaluated correlation analysis of the recorded data. Evaluation results were used for identifying models basic architecture. Two custom software toolboxes were developed for developing hybrid systems; namely the EVolution Of Fuzzy INference Engines (EVOFINE) and the FUzzy Neural (FUN) toolbox. Eight hybrid systems developed with EVOFINE, FUN, ANFIS and ANN techniques were evaluated against applied clinical decisions and patient scenarios. Results: Seventeen (17) models were designed for each of the eight (8) modeling techniques. The modelled process consisted of twelve physiology variables and six ventilator settings. The number of models’ inputs ranged from single to six based on correlation and evaluation findings. Evaluation against clinical recommendations has shown that ANNs performed better; mean average error as percentage for four of the applied techniques was 0.16%, 1.29% & 0.62 for ANN empirical, 0.05%, 2.23% & 2.30% for ANFIS, 0.93%, 2.33% & 1.89% for EVOFINE and 0.73%, 2.63% & 6.56 for FUN NM, in Normal, COPD and ALI-ARDS categories respectively. Additionally evaluation against clinical disagreement SD has shown that 70.6% of the NN empirical models were performing in 90% of their suggestions within clinical SD, while the percentages were 53%, 53% and 59% for the EVOFINE, ANFIS and NN Normalized models respectively. The EVOFINE and ANFIS produced Fuzzy Systems whose architecture is transparent for the user. Visual observation of ANFIS architectures revealed possibly hazardous advices. Evaluation against clinical disagreement has shown that the NN empirical was not producing hazardous advices, while EVOFINE, ANFIS and NN Normalized were shown to produce potentially hazardous advice in 17.6%, 23% and 5.8% of the developed models

Separator fluid volume requirements in multi-infusion settings

INTRODUCTION. Intravenous (IV) therapy is a widely used method for the administration of medication in hospitals worldwide. ICU and surgical patients in particular often require multiple IV catheters due to incompatibility of certain drugs and the high complexity of medical therapy. This increases discomfort by painful invasive procedures, the risk of infections and costs of medication and disposable considerably. When different drugs are administered through the same lumen, it is common ICU practice to flush with a neutral fluid between the administration of two incompatible drugs in order to optimally use infusion lumens. An important constraint for delivering multiple incompatible drugs is the volume of separator fluid that is sufficient to safely separate them. OBJECTIVES. In this pilot study we investigated whether the choice of separator fluid, solvent, or administration rate affects the separator volume required in a typical ICU infusion setting. METHODS. A standard ICU IV line (2m, 2ml, 1mm internal diameter) was filled with methylene blue (40 mg/l) solution and flushed using an infusion pump with separator fluid. Independent variables were solvent for methylene blue (NaCl 0.9% vs. glucose 5%), separator fluid (NaCl 0.9% vs. glucose 5%), and administration rate (50, 100, or 200 ml/h). Samples were collected using a fraction collector until <2% of the original drug concentration remained and were analyzed using spectrophotometry. RESULTS. We did not find a significant effect of administration rate on separator fluid volume. However, NaCl/G5% (solvent/separator fluid) required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). Also, G5%/G5% required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). The significant decrease in required flushing volume might be due to differences in the viscosity of the solutions. However, mean differences were small and were most likely caused by human interactions with the fluid collection setup. The average required flushing volume is 3.7 ml. CONCLUSIONS. The choice of separator fluid, solvent or administration rate had no impact on the required flushing volume in the experiment. Future research should take IV line length, diameter, volume and also drug solution volumes into account in order to provide a full account of variables affecting the required separator fluid volume

An investigation into the effects of commencing haemodialysis in the critically ill

&lt;b&gt;Introduction:&lt;/b&gt; We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. &lt;b&gt;Methods:&lt;/b&gt; Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of &gt;+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. &lt;b&gt;Results:&lt;/b&gt; Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (&gt;+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. &lt;b&gt;Conclusions:&lt;/b&gt; Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature