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Decision-support for Mechanical Ventilation
Alan H. Morris, M.D.
European Society for Computing and Technology in Anesthesia and Intensive
Care, Amsterdam, 8 October 2010
No Conflict of InterestNo Commercial Association
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1.Need for decision-support (clinician uncertainty, human performance)
2.Science and reproducibility
3.Decision-support (influence clinician behavior)
PCIRV… LFPPV-ECCO2R
Mechanical Ventilation
ARDS
Randomize
Extubation DeathExtubationDeath
NIH N01-HL 46062 Alan H. Morris, M.D.
Computerized Protocols Developed1985-87
1987-91
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Clinical Uncertainty- Complexity: >236 Variable Categories
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1.Need for decision-support (clinician uncertainty)
2.Science and reproducibility
3.Decision-support (influence clinician behavior)
Douglas C. Giancoli. Physics. prentice Hall, Englewood Cliffs, NJ 1995:3
Science:testing..experiments..distinguish science from other creative fields
(key is the belief that true results can be reproduced by others.
Reproducibility requires a detailed and explicit method)
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• High-quality clinical trials require consistent compliance with evidence-based guidelines.
• High compliance makes the clinical trial more reproducible – a requirement of good science.
• Differences in clinician compliance with guidelines/study protocol could influence the results of clinical trials
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Requirement of good science:• Reproducibility is what confirms the
proper description of nature’s behavior.
• If one scientist has properly described nature's behavior, another scientist using the same method should obtain the same result.
Requirement of good science:• Replication of experimental results
is a primary requirement before new scientific information is embraced by the standard works of the domain (e.g., textbooks).
• Replication of results depends on reproducible methods.
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The hospital, the operating room, and the
wards should be laboratories, laboratories
of the highest order.William S. Halsted, M.D.
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Experimental Human Clinical Outcomes Research Laboratory:
1. Good Clinical Care2. Ethical Care
3. Reliable Data Capture4. Standardized Clinician Response
(Reproducible Method)
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1.Need for decision-support (clinician uncertainty)
2.Science and reproducibility
3.Decision-support (influence clinician behavior) – adaptive expert system
Medical subject headings - Ovid®:• Guideline: “A systematic statement of policy rules or principles”-where to go but not how to get there
• Protocol: “Precise and detailed plans for the study of a medical or biomedical problem and/or for a regimen of therapy.”-how to get there
(Adequately explicit protocol: enough detail to lead different clinicians to the same patient-specific decision - reproducible clinical decision method) 13
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王皓在比赛中
马琳在比赛中
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Guideline“Win the point”
Inadequately explicit protocol“Hit the left corner”
Adequately explicit protocol“Wait for a high return and hit the
ball hard with a left spin, curving to the opponent’s left, to land within 1 inch of the left corner of the table.”
Meehl P. Clinical versus statistical prediction - a theoretical analysis and a review of the evidence. Minneapolis: University of Minnesota Press 1954.
McDonald C, Overhage J. JAMA 1994;271(11):872-873.Tierney WM et al. J Am Med Informatics Assn 1995;2(5):316-22.Zielstorff R. J Am Med Informatics Assn 1998;5(3):227-236.
Inadequately explicit
Try to return to FIO2=0.4 and PEEP=5 as soon as
possible.
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Decline 5% of recommendations
Accept 95% of recommendations
Patient data:• SpO2, PaO2, pH• Respiratory Care
Patient-specific instructions:Mode, Tidal Volume, Rate,
FIO2, Ppeak, PEEP
Capture reason for decliningClinician
Accepts or DeclinesPatient
Computer Protocol Continual Operation (Mechanical Ventilation Protocol Example)
eProtocol-Mechanical-Ventilation vs. Controls (usual care)
Unpublished data from an RCT
Box = interquartile range (IQR) and median
Bars = IQR limits ± ~1.5 IQR
97 Patients
FIO2 ≤0.6Pplateau ≤35 cm H2OTarget VT =7 ml/kg PBW
103 Patients
Goals
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Pplateau >35 cm H2O x Days
Inspired %O2 >60 x Days
AHCPR #HS06954 (T East, PhD, PI)
Patient is ready for a 5 min test for inspiratory effort. Reduce Ventilator Set Rate to 10. Enter Total Ventilatory Rate when it exceeds 10 or at the end of 5 min.
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Complexity is transparent (hidden)
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MAP 60 mm Hg
Avg. 4 hour Urine < 0.5
ml/kg/hr
Avg. 4 hr Urine ≥0.5
ml/kg/hr
PAOP
(mm Hg)
MAP
< 60 mm Hg
(See shock protocol
on reverse)
Ineffective Circulation
C.I. < 2.5
Effective
Circulation C.I. 2.5
Ineffective Circulation
C.I. < 2.5
Effective
Circulation C.I. 2.5
> 24
KVO IV 3 DobutamineA FurosemideB
KVO IV 7 FurosemidB
KVO IV 11 DobutamineA FurosemideB
KVO IV 15 FurosemidB
19-24
Vasopressor KVO IV 4 DobutamineA
KVO IV 8 FurosemideB
KVO IV 12 DobutamineA
KVO IV 16 Furosemide
B
14-18 Fluid bolusC 5 Fluid bolusC 9
Fluid bolusC
13 KVO IV 17
< 14
Fluid bolusD
Fluid bolusC 6 Fluid bolusC
10 Fluid bolusC
14 Fluid bolusC
19
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C. Fluid Bolus (Non-shock, except cell #19):1. Administer 15 ml/kg PBW normal saline, Plasmalyte,
or Ringer’s lactate (rounded to the nearest 250 ml) or 1 unit RBCs or 25 grams albumin (choice at discretion of physician) over <= 1 hour then reassess patient.For cells 5, 6, 9, 10, reassess within one hour. Administer up to 3 boluses over 24 hours if indicated by protocol.This 24 hour period begins with the first protocol-mandated non-shock bolus OR the first protocol-mandated bolus following shock reversal.
2. Additional fluid boluses are allowed at the discretion of the physician.
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Blood Glucose/Insulin Protocol: Adults and Children
Blood Glucose/Insulin Protocol: Adults and Children
% M
easu
rem
ents
Blood Glucose (mg/dl)
8
6
4
2
0 0 40 80 120 160 200 240 280 320
Bedside Computer ProtocolBedside Paper Protocol
Simple Guideline
P<0.0001786 Patients
44,979 Measurements
→Target
Range
% M
easu
rem
ents
Blood Glucose (mg/dl)
8
6
4
2
0 0 40 80 120 160 200 240 280 320
Western USASoutheast USANortheast USASingapore
P=0.18753 Patients
36,302 Measurements
→Target
Range
Blood Glucose Computer Protocol
1Mar07
Thompson, BT et al. J Diabetes Sci Technol 2008;2(3):357-68
99 Adults - 6 ICUs48 Children - 5 ICUs
% Blood Glucose Measurements9876543210
0 40 80 120 160 200 240 280 320Blood Glucose (mg/dl by 5 mg/dl groups)
ΔAdultPediatric
Translation: ResearchPractice
13 Adult ICUs: Intermountain Healthcare Intensive Medicine Clinical Program in 7 hospitals ranging from a:
72 bed primary care hospitalto a
480 bed tertiary care hospital
% M
easu
rem
ents
Blood Glucose (mg/dl)
8
6
4
2
0 0 40 80 120 160 200 240 280 320
ICU Type Pa-tients
Measure-ments
Research 493 21,321Clinical Care 2,296 109,458
→Target
Range
Blood Glucose Computer Protocol
eProtocols: reproducible method
• Adult and pediatric ICUs(bridge different disciplines)• In usual clinical care(translate research to practice)
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1.Need for decision-support (clinician uncertainty, human performance)
2.Science and reproducibility
3.Decision-support (influence clinician behavior)
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36
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Statistic Adult Pediatric Tota l Patients 99 48 147 Measurements 8269 4617 12,886 % Instructions
Accepted 95
(7786/8230) 91
(4165/4603) 93
(11951/12833) Blood glucose:
Baseline 157 180 164 Mean 116 118 117
SD 38 39 38 Maximum 556 580 580 Minimum 29 20 20 % 70-110
mg/dL 47
(3888/8269) 48
(2208/4617) 47
(6096/12886)
NIH Roadmap contract # HHSN268200425210C: 1Mar07
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% ≤ 40 mg/dL (2.22 mmol/L):
ICU all glucose
measurements
patients with ≥1
measurement
Adult 0.10 (8/8269) 7 (7/99)
Pediatric 0.32 (15/4617) 19 (9/48)
Tota l 0.18 (23/12886) 11 (16/147)
NIH Roadmap contract # HHSN268200425210C: 1Mar07
0.5% stop - a priori
CPAP weaning trial successful. Click red CONFIRM button and switch ventilator to Pressure Support mode with PS=20 cm H2O, PEEP=5 and FIO2=0.5 if you want to proceed. Then wait and enter total ventilatory rate, SpO2 and evaluate for respiratory distress within 5 min.
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40
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Crit Care Med ‘08;361787–95)
% M
easu
rem
ents
Blood Glucose (mg/dl)
• Bedside Computer Protocol∆ Bedside Paper Protocol+ Simple Guideline
P<0.0001
→Target
Range 8
6
4
2
0 0 40 80 120 160 200 240 280 320
Local research group
Multiple IH sites
Multiple sites- geographically dispersed
Increasing levels of clinician trust - must abandon personal style
Clinician leader
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• Unnecessary variation, and error, exist in medical care.
• Computer protocols help clinicians deliver consistent, evidence-based, care with a reproducible method.
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1.Need for decision-support (clinician uncertainty, human performance)
2.Science and reproducibility
3.Decision-support (influence clinician behavior)
% of 15,381 Heart Failure Outpatients ReceivingAppropriate Guideline-
Based Treatment In 165 clinics
Maximum90% of clinics
Median
10% of clinicsMinimum
Legend:Range of results bystudy clinic
%
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0
1234
Sur
viva
l
Months Following DischargeRe: (Kfoury, French – Intermountain Nov 2008)
Adherence to Heart Failure Core Measures
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%
0
20
40
60
80
100
Audit 4
Interview92
1816141210876543210
40
30
20
10
0
N
VT (ml/kg PBW)
Evidence
Adhere to “Best Practice?“
Brunkhorst F, Engel C, Ragaller M, Welte T, Rossaint R, Gerlach H, et al. Practice and perception—A nationwide survey of therapy habits in sepsis. Crit Care Med. 2008;36(10):1-6
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Miller, GA. Psychological Review 1956;63(2):81-97
East, TD et al. Chest 1992;101:697-710 (PCIRV)
Cowan N. Behav Brain Sci 2001;24:87
# Conceptual Objects Humans Can Accommodate (“Chunks” in Short
Term Memory) Before Decisions are Degraded
~ 7
~ 4
Proteomics
Functional Genetics
Structural Genetics
Clinical Phenotype
Fac
ts /
Dec
isio
n
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The Roundtable on Evidence-Based Medicine: Learning Healthcare System Concepts v. 2008. Annual Report, IOM, Nat Acad Sci . P9, IOM Meeting, 8 October 2007. Growth in facts affecting provider decisions versus human cognitive capacity .
This limit makes protocol rule generation easier, and manageable.
1000
100
10Human Cognitive 5 Capacity
William Stead, MD – Challenges to Providers
Decision-support (patient-clinician encounter scale)
•Involve end-users•Quick testing of an idea•Trust
R Clemente
H Aaron L Gehrig
“Strike him out”57W Mays
B Ruth
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Guideline“Strike him out”
Inadequately explicit protocol“Curve ball low and inside”
Adequately explicit protocol“Throw a 67 mile per hour curve
ball low and inside within 1 inch of the back corner of the plate and 2 inches above the left knee, after a 45 second pause”