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BiosensorsBiosensorsData forData for
Systems AnalysisSystems Analysis
DuringDuring
ConvalescenceConvalescence
Palmer Q. Bessey, MDPalmer Q. Bessey, MD
Burn CenterBurn Center
Weill Medical CollegeWeill Medical College
Biomedical Engineering Biomedical Engineering RetreatRetreat
Ithaca, NYIthaca, NY27 July 200727 July 2007
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Systems Analysis :“.. study of a system ... in an attempt to elucidate its effectiveness or performance ... and the effect of parameter variations on these quantities.”
System :Multiple components (subsystems)
Large and complex.
Complicated inter-relationships
Integrity – Common purpose
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Systems Analysis :“.. study of a system ... in an attempt to elucidate its effectiveness or performance ... and the effect of parameter variations on these quantities.”
System :Multiple components (subsystems)
Large and complex.
Complicated inter-relationships
Integrity – Common purpose
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
The Surgical Patient is a SystemThe Surgical Patient is a SystemComponents (Sub-systems) : Components (Sub-systems) :
CardiovascularCardiovascular MetabolicMetabolic
PulmonaryPulmonary NeurologicNeurologic
RenalRenal HematologicHematologic
Gastro-intestinalGastro-intestinal ImmunologicImmunologic
Large and complex.Large and complex.
Complicated Inter-relationshipsComplicated Inter-relationships
Integrity. Integrity. Common purpose: RecoveryCommon purpose: Recovery
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
The Surgical Patient is a SystemThe Surgical Patient is a SystemAltered Normal Homeostasis.Altered Normal Homeostasis.
Threats of Operation (Injury) : Threats of Operation (Injury) : Tissue Disruption Tissue Disruption HemorrhageHemorrhage
Ischemia / Hypoxia Ischemia / Hypoxia AcidosisAcidosis
Bacterial ContaminationBacterial Contamination TransfusionTransfusion
Re-perfusionRe-perfusionHypothermia Hypothermia
Complicated Inter-relationships.Complicated Inter-relationships.
Integrity. Integrity. Common purpose: RecoveryCommon purpose: Recovery
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Task of Convalescent Care :Guide the patient through recovery.
Systems Analysis :Gather and assemble performance data
Analysis – Efficacy.
Risk assessment.
Decision making regarding intervention
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Hypothesis :Hypothesis :The care and treatment of The care and treatment of
... patients is best done ... patients is best done
using numerical data using numerical data
in an orderly set of rules.in an orderly set of rules.
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Data Sources :Events Vital signs
Nurse observations MD observations
Physiologic measures Lab data
Special studies Imaging
Analysis and Decision Making :
Gathering data Multiple individuals
Knowledge differences Efficiency
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Interventions : Interventions :
Risk AssessmentRisk Assessment Lead timeLead time
End point – DoseEnd point – Dose Feed backFeed back
Issues :Issues :Time consuming Time consuming Multiple stepsMultiple steps
CommunicationCommunication Incomplete dataIncomplete data
Error prone Error prone Delayed feed backDelayed feed back
Risks – All interventions / monitoring Risks – All interventions / monitoring
Opportunites :Opportunites :
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis – OpportunitiesSystems Analysis – Opportunities
More Complete Performance Data :
For any / all compents (sub-systems)Cardiac performance (organ perfusion)
Respiratory work / efficacy (gas exchange)
Blood glucose
Hematology / Immunology
Wound healing
Balance usefulness vs. invasivenessLess invasive is better.
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis – OpportunitiesSystems Analysis – Opportunities
More Timely Data :
Point of care testing.
Real time data
More Efficient Decision Making
Standardized patient care protocols.
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
HyperglycemiaHyperglycemia
Clinical Effects :
Impairs PMN / Immunologic defenses
Increased incidence of infection
Increased vascular tone / hypoperfusion.
Increased ventilatory work (CO2 Production)
Exaggerate hypermetabolism
Impaired wound healing
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007Control of HyperglycemiaControl of Hyperglycemia
Van Den Bergh, 2001Van Den Bergh, 2001
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007Control of HyperglycemiaControl of Hyperglycemia
Van Den Bergh, 2001Van Den Bergh, 2001
CORNELL
U N I V E R S I T Y
William Randolph Hearst Burn Center
NEWYORK
PRESBYTERIAN
H O S P I T A L
NY CORNELL BURN CENTER ICU INSULIN PROTOCOL 2005 INITIAL INSULIN DOSING Glucose
121 - 150 mg/dl
151 - 200 mg/dl
201 - 250 mg/dl
251 - 300 mg/dl
301 - 350 mg/dl
> 350 mg/dl
Insulin Dose
Give 2 U insulin IVP. Start drip @ 2 U / hr
Give 3 U insulin IVP. Start Drip @ 3 U / hr
Give 4 U insulin IVP. Start Drip @ 4 U / hr
Give 5 U insulin IVP. Start Drip @ 5 U / hr
Give 6 U insulin IVP. Start Drip @ 6 U / hr
Give 10 U IVP
Start Drip @ 8 U / hr
GOAL: Maintain blood glucose measured at bedside in range of 81 - 110 mg/dl.
ONGOING INSULIN DOSING
ONGOING INSULIN DOSING Glucose
Level
Current Drip Rate
1-3 U / hr
Current Drip Rate
4-6 U / hr
Current Drip Rate
7-9 U / hr
Current Drip Rate
10 - 12 U / hr
Current Drip Rate
13 - 16 U / hr
Current Drip Rat
> 16 U / hr
> 350 mg/dl
Give 6 U Insulin IVP
Increase Drip by 6 U / hr
Give 6 U Insulin IVP
Increase Drip by 6 U / hr
Give 6 U Insulin IVP
Increase Drip by 6 U / hr
Give 6 U Insulin IVP
Increase Drip by 6 U / hr
Give 6 U Insulin IVP
Increase Drip by 6 U / hr
Give 6 U Insulin IVP
Increase Drip by 6 U / hr
301- 350
mg/dl
Give 5 U insulin IVP
Increase Drip by 5 U / hr
Give 5 U insulin IVP
Increase Drip by 5 U / hr
Give 5 U insulin IVP
Increase Drip by 5 U / hr
Give 5 U insulin IVP
Increase Drip by 5 U / hr
Give 5 U insulin IVP
Increase Drip by 5 U / hr
Give 5 U insulin IVP
Increase Drip by 5 U / hr
251- 300
mg/dl
Give 4 U insulin IVP
Increase Drip by 4 U / hr
Give 4 U insulin IVP
Increase Drip by 4 U / hr
Give 4 U insulin IVP
Increase Drip by 4 U / hr
Give 4 U insulin IVP
Increase Drip by 4 U / hr
Give 4 U insulin IVP
Increase Drip by 4 U / hr
Give 4 U insulin IVP
Increase Drip by 4 U / hr
201- 250
mg/dl
Give 3 U insulin IVP
Increase Drip by 3 U / hr
Give 3 U insulin IVP
Increase Drip by 3 U / hr
Give 3 U insulin IVP
Increase Drip by 3 U / hr
Give 3 U insulin IVP
Increase Drip by 3 U / hr
Give 3 U insulin IVP
Increase Drip by 3 U / hr
Give 3 U insulin IVP
Increase Drip by 3 U / hr
171- 200
mg/dl
Give 2 U insulin IVP.
Increase Drip by 2 U / hr
Give 2 U insulin IVP.
Increase Drip by 2 U / hr
Give 2 U insulin IVP.
Increase Drip by 2 U / hr
Give 2 U insulin IVP.
Increase Drip by 2 U / hr
Give 2 U insulin IVP.
Increase Drip by 2 U / hr
Give 2 U insulin IVP.
Increase Drip by 2 U / hr
141- 170
mg/dl
Give 1 U insulin IVP.
Increase Drip by 1 U / hr
Give 1 U insulin IVP.
Increase Drip by 1 U / hr
Give 1 U insulin IVP.
Increase Drip by 1 U / hr
Give 1 U insulin IVP.
Increase Drip by 1 U / hr
Give 1 U insulin IVP.
Increase Drip by 1 U / hr
Give 1 U insulin IVP.
Increase Drip by 1 U / hr
111- 140
mg/dl
No insulin IVP.
Increase Drip by 1 U / hr
No insulin IVP.
Increase Drip by 1 U / hr
No insulin IVP.
Increase Drip by 1 U / hr
No insulin IVP.
Increase Drip by 1 U / hr
No insulin IVP.
Increase Drip by 1 U / hr
No insulin IVP.
Increase Drip Rate by 1 U / hr
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Control of HyperglycemiaControl of Hyperglycemia
43 yom, Sepsis, ARDS, Renal Failure 43 yom, Sepsis, ARDS, Renal Failure 65% 65% BSABBSABPBD # 11 - 12PBD # 11 - 12 Tube Tube FeedingsFeedings
0
50
100
150
200
250
0 2 4 6 8 10 12 14 16 18 20 22 24 26
Time (hr)
Glucose (mg/dl)
0
5
10
15
20
Insulin Dose (U)
BolusDrip
Glucose
Insulin Protocol - Nursing WorkInsulin Protocol - Nursing Work
0
200
400
600
800
1000
1200
1400
1600
1800
TotalSamples
HourlySamples
Adjustments AdjustmentHeld
ExtraAdjustment
Glucose Measurements
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Insulin Protocol - PerformanceInsulin Protocol - Performance
0
200
400
600
800
1000
< 60 60 - 120 120 - 150 150-180 >180
Blood Glucose (mg/dl)
Glucose Measurements
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Insulin ProtocolInsulin ProtocolSummary and Conclusions :
N = 17 patients, 99 24-hour periods
Nutritional Intake: 1,938 ± 57 kcal/24 hr
Total daily insulin dose: 133 ± 12 U/24 hr
POC Glucose determinations: 1,849
Hourly POC Glucose: 1,528 (83 %)
Under 60 or over 180 mg/dl: 79 (4.3%)
Conclusion :Conclusion :Insulin protocol safe and effective.
Adds substantially to nursing work load.
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis in Surgical Systems Analysis in Surgical PatientsPatients
Hypothesis :Hypothesis :
The care and treatment of The care and treatment of
... patients is best done ... patients is best done
using numerical data using numerical data
in an orderly set of rules. in an orderly set of rules.
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007
Systems Analysis – OpportunitiesSystems Analysis – Opportunities
Automation :
Sheppard et al, Ann Surg, 1968.
154 Cardiac Surgery Patients154 Cardiac Surgery Patients
BP, LAP, Urine output, Chest tube drainage.BP, LAP, Urine output, Chest tube drainage.
Automated protocol for blood infusion -- RulesAutomated protocol for blood infusion -- Rules
More reliable, consistentMore reliable, consistent
More efficientMore efficient
Cost effectiveCost effective
SaferSafer
Biomedical Engineering Biomedical Engineering RetreatRetreatIthaca, NYIthaca, NY 27 July 27 July 20072007