Dissertations / Theses on the topic 'Critical care monitoring'

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 2007.
This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.
Includes bibliographical references (p. 231-239).
In modern intensive care units (ICUs) a vast and varied amount of physiological data is measured and collected, with the intent of providing clinicians with detailed information about the physiological state of each patient. The data include measurements from the bedside monitors of heavily instrumented patients, imaging studies, laboratory test results, and clinical observations. The clinician's task of integrating and interpreting the data, however, is complicated by the sheer volume of information and the challenges of organizing it appropriately. This task is made even more difficult by ICU patients' frequently-changing physiological state. Although the extensive clinical information collected in ICUs presents a challenge, it also opens up several opportunities. In particular, we believe that physiologically-based computational models and model-based estimation methods can be harnessed to better understand and track patient state. These methods would integrate a patient's hemodynamic data streams by analyzing and interpreting the available information, and presenting resultant pathophysiological hypotheses to the clinical staff in an effcient manner. In this thesis, such a possibility is developed in the context of cardiovascular dynamics. The central results of this thesis concern averaged models of cardiovascular dynamics and a novel estimation method for continuously tracking cardiac output and total peripheral resistance. This method exploits both intra-beat and inter-beat dynamics of arterial blood pressure, and incorporates a parametrized model of arterial compliance. We validated our method with animal data from laboratory experiments and ICU patient data.
(cont.) The resulting root-mean-square-normalized errors -- at most 15% depending on the data set -- are quite low and clinically acceptable. In addition, we describe a novel estimation scheme for continuously monitoring left ventricular ejection fraction and left ventricular end-diastolic volume. We validated this method on an animal data set. Again, the resulting root-mean-square-normalized errors were quite low -- at most 13%. By continuously monitoring cardiac output, total peripheral resistance, left ventricular ejection fraction, left ventricular end-diastolic volume, and arterial blood pressure, one has the basis for distinguishing between cardiogenic, hypovolemic, and septic shock. We hope that the results in this thesis will contribute to the development of a next-generation patient monitoring system.
by Tushar Anil Parlikar.
Ph.D.

Cardiovascular disease is a large problem in the intensive care unit (ICU) due to its high prevalence in modern society. In the ICU, intensive monitoring is required to help diagnose cardiac and circulatory dysfunction. However, complex interactions between the patient, disease, and treatment can hide the underlying disorder. As a result, clinical staff must often rely on their skill, intuition, and experience to choose therapy, increasing variability in care and patient outcome. To simplify this clinical scenario, model-based methods have been created to track subject-specific disease and treatment dependent changes in patient condition, using only clinically available measurements. The approach has been tested in two pig studies on acute pulmonary embolism and septic shock and in a human study on surgical recovery from mitral valve replacement. The model-based method was able to track known pathophysiological changes in the subjects and identified key determinants of cardiovascular health such as cardiac preload, afterload, and contractility. These metrics, which can be otherwise difficult to determine clinically, can be used to help provide targets for goal-directed therapies to help provide deliver the optimal level of therapy to the patient. Hence, this model-based approach provides a feasible and potentially practical means of improving patient care in the ICU.

Pneumonia and ventilator associated pneumonia (VAP) are a frequent cause for admission to Intensive Care and complication of ventilation respectively. VAP occurs in 10-40% of patients requiring mechanical ventilation and is associated with increased mortality, morbidity and healthcare costs. Diagnosis can be difficult due to poor predictive value of clinical features and low specificity of radiological changes. Bronchoscopic techniques are often invasive, may not be suitable for all patients and are not without complications. New tests are required to improve the diagnosis of these conditions allowing early, appropriate antibiotic treatment. In this study several techniques were used to explore the value of profiling of a range of biofluids obtained from ventilated patients as an aid to diagnosis of pneumonia. Patients were recruited from Intensive Care with either a diagnosis of pneumonia or brain injury. Those with brain injuries were tracked to identify patients who developed VAP. Serum, urine and exhaled breath condensate (EBC) were collected from all patients. Metabonomics, an approach that identifies changes in metabolic profiles associated with disease, was applied using proton nuclear magnetic resonance spectroscopy to both blood and urine and with mass spectrometry (MS) to exhaled breath condensate. Following from the metabonomic work a panel of inflammatory mediators, including cytokines and eicosanoids were measured in serum using MS and flow cytometry to explore the inflammatory changes in these patients. Overall metabolic and inflammatory profiling of serum showed potential as an adjunct to clinical diagnosis especially when combined with clinical data. Analysis of urine and EBC proved more challenging due the number of drug metabolites and low concentration of metabolites they respectively contained. In summary this study has added to the field by demonstrating the potential for profiling techniques of serum from critically ill patients to assist in the diagnosis of both pneumonia and VAP.

Statement of the Problem: Source data verification (SDV) is the process of comparing data collected at the source to data recorded on a Case Report Form, either paper or electronic (1) to ensure that the data are complete, accurate and verifiable. Good Clinical Practice (GCP) Guidelines are vague and lack evidence as to the degree of SDV and whether or not SDV affects study outcomes. Methods of Investigation: We performed systematic reviews to establish the published evidence-base for methods of SDV and to examine the effect of SDV on study outcomes. We then conducted a national survey of Canadian Critical Care investigators and research coordinators regarding their attitudes and beliefs regarding SDV. We followed by an audit of the completed and in-progress Randomized Controlled Trials (RCTs) of the Canadian Critical Care Trials Group (CCCTG). Results: Systematic Review of Methods of SDV: The most common reported or recommended frequency of source data verification (10/14 - 71%) was either based on level or risk, or that it be conducted early (i.e. after 1st patient enrolled). The amount of SDV recommended or reported, varied from 5-100%. Systematic Review of Impact of SDV on Study Outcomes: There was no difference in study outcomes for 1 trial and unable to assess in the other. National Survey of Critical Care Investigators and Research Coordinators: Data from the survey found that 95.8% (115/120) of respondents believed that SDV was an important part of Quality Assurance; 73.3% (88/120) felt that academic studies should do more SDV; and 62.5% (75/120) felt that there is insufficient funding available for SDV. Audit of Source Data Verification Practices in CCCTG RCTs: In the national audit of in-progress and completed CCCTG RCTs, 9/15 (60%) included a plan for SDV and 8/15 (53%) actually conducted SDV. Of the 9 completed published trials, 44% (4/9) conducted SDV. Conclusion: There is little evidence base for methods and effect of SDV on study outcomes. Based on the results of the systematic review, survey, and audit, more research is needed to support the evidence base for the methods and effect of SDV on study outcomes.

Critical illness survivorship is frequently characterised by profound long-term physical and psychological disabilities. These arise as a result of the complex interaction between the patho-physiological e ects of critical illness, clinical interventions and the impact of prolonged bed rest on physical and psychological health. Early rehabilitation in the ICU is an important intervention that can overcome some of the devastating impacts of critical illness on patients and their carers. However, with little or no scienti c basis for its prescription and no validated means of assessing individual patient workload during rehabilitation, a \one-size- ts-all" approach is generally adopted. In contrast, the eld of sports science has an extensive literature base describing the optimisation of individual training programs. This thesis explores the potential translation of key precepts of exercise physiology into the ICU setting in order to quantify the workload during rehabilitation in mechanically ventilated (MV) patients recovering from critical illness. Breath-by-breath-gas-exchange-analysis (BBGEA) is the gold standard for measuring exercise capacity and intensity in non-ventilated individuals. However, validated devices in MV patients are lacking. In this thesis the MedGraphics Ultima, a BBGEA device, was validated in the critical care setting, within the limits of two reference techniques; Douglas bag collection and Deltatrac II. The feasibility of using BBGEA in patients rehabilitating in the ICU and the oxygen cost of this rehabilitation were then investigated. I established that, while this device is an invaluable research tool, it is impractical for day-to-day clinical practice. I further identi ed that the oxygen cost of rehabilitation activities in the ICU is not directly activity-dependent. I then developed two models to generate proxy values of oxygen consumption, during rehabilitation interventions, evaluating their performance with a small validation sample. The huge variations in the exercise load of rehabilitation interventions between and within patients highlights the need to establish personalised exercise regimens.

Thesis (MMed)-- Stellenbosch University, 2013.
ENGLISH ABSTRACT: Introduction: Of the volatile anaesthetic agents, desflurane causes the greatest degree of potentiation of the neuromuscular blocking drugs (NMB). The purpose of this study was to determine whether desflurane prolongs the effects of 3xED95 doses of rocuronium and cisatracurium to the same degree. The two NMB represent potent and less potent classes respectively. Methods: Informed, written consent was obtained from 63 adult patients scheduled for routine surgery. They were randomly allocated to one of four groups to receive either desflurane-sufentanil (end-tidal partial pressure 4.0 kPa) or propofol-sufentanil anaesthesia and either rocuronium (0.9mg/kg) or cisatracurium (0.15mg/kg). All patients received a target-controlled sufentanil infusion (0.5 ng/ml). Neuromuscular blockade was recorded using accelerometry (TOFGUARD ®, Organon) while patients recovered spontaneously to a Train-of-Four ratio of 0.9 (TOFR0.9). Data were analysed using one- and two-way analysis of variance. The main effects were the types of anaesthetic and NMB on indices of recovery. Results: Compared with propofol-sufentanil anaesthesia, mean times to recovery to T125% and TOFR0.9, were prolonged by desflurane-sufentanil (p<0.01). There were no interactions. Mean prolongation of time to TOFR0.9 was 41 min (SD 36) for cisatracurium and 26.6 min (SD 39) for rocuronium. Discussion: Whereas previous studies did not reveal prolongation of the duration of action of rocuronium by desflurane, we demonstrated a statistically significant prolongation of the spontaneous recovery times of both rocuronium and cisatracurium by desflurane. From the data we could not conclude that there was a difference between the two NMB. A power study revealed that in order to detect a difference between times to recovery to TOF0.9, a sample size of 101 subjects per group would be required. Conclusion: Desflurane prolongs the mean time to spontaneous recovery from neuromuscular blockade after 3xED95 doses of both cisatracurium (a potent NMB) and rocuronium (a less potent NMB). There was wide inter-individual variation in times to spontaneous recovery. Any difference in the mean prolongations between the different types of NMB is unlikely to be of clinical importance.
AFRIKAANSE OPSOMMING: Inleiding Van al die vlugtige narkosemiddels veroorsaak desfluraan die grootste mate van potensiasie van die neuromuskulêre blokkeermiddels. Die doel van hierdie studie was om vas te stel of desfluraan wel die effek van driedubbel die ED95 dosis van rokuronium en cisatrakurium tot dieselfde mate sal verleng. Metodiek Geskrewe ingeligte toestemming is verkry van 63 pasiënte wat voorgedoen het vir roetiene chirurgiese prosedures. Pasiënte is lukraak in een van vier groepe ingedeel om of desfluraansufentaniel (eind-gety parsieële druk 4.0 kPa) of propofol-sufentaniel narkose en of rokuronium (0.9 mg/kg) of cisatrakurium (0.15 mg/kg) te ontvang. Alle pasiënte het 'n teiken-beheerde sufentaniel infusie (0.5 ng/ml). Neuromuskulêre blokkade is waargeneem met behulp van aksellerometrie (TOF-GUARD, Organon) terwyl pasiënte spontaan herstel het tot “reeks-van-vier” verhouding (Engels “Train-of-four” ratio) 0.9 (TOFR0.9). Data analise is gedoen met behulp van een- en tweerigting analise van variansie. Resultate Desfluraan-sufentaniel het die gemiddelde hersteltyd tot T125% en TOFR0.9 verleng in vergelyking met propofol-sufentaniel. Geen interaksies is waargeneem nie. Gemiddelde verlenging van TOFR0.9 vir cisatrakurium was 41 minute (standaardafwyking 36) en vir rokuronium 26.6 minute (standaardafwyking 39). Bespreking Vorige studies kon nie vasstel of desfluraan die werkingsduur van rokuronium verleng nie. Ons het in hierdie studie vasgestel dat desfluraan wel 'n statisties beduidende verlenging in die hersteltyd van beide rokuronium en cisatrakurium veroorsaak. Ons kon egter nie 'n verskil tussen die twee neuromuskulêre agente aandui nie. 'n onderskeidingsvermoëstudie het getoon dat ten minste 101 pasiënte per groep benodig sou word om 'n beduidende verskil tussen die hersteltye tot TOFR0.9 te verkry. Gevolgtrekking Desfluraan verleng die gemiddelde hersteltyd tot spontane herstel van neuromuskulêre blokkade na driedubbele ED95 dosisse van beide cisatrakurium en rokuronium. Daar was egter groot interindividuele variasie ten opsigte van spontane hersteltyd. Enige verskille in die gemiddelde verlenging is onwaarskynlik van kliniese belang.

Tracheal cuff pressure monitoring plays a significant role in the care of patients in the critical care environment. Most patients in critical care environment are intubated with cuffed tubes via the ore or the naso-tracheal route, or a tracheostomy is performed. The purpose of the tracheal cuff is to maintain a seal between the tube and the tracheal wall, to prevent volume loss and ensure effective mechanical ventilation. Nurse practitioners in the critical care environment play a vital role in monitoring tracheal cuff pressure, which is often neglected in clinical practice. Purpose: To investigate the effect of an intervention on tracheal cuff pressure monitoring in the critical care environment of an academic hospital in Gauteng. Design and methods: A quantitative prospective non-experimental comparative design, with a collaborative qualitative method. The study had a pre and post intervention phase to compare the effect on an intervention. Findings: The study findings during the pre-intervention phase revealed inconsistency in the monitoring, night time monitoring poor and the found and the adjusted pressure documentation poor. Most pressures found to be non-compliant and serious non-compliant. The post-intervention results revealed an improvement in the night monitoring, but pressures were still found to be high. The consistency in the frequency of monitoring remains poor. Recording of the found and adjusted pressure had a small improvement. Conclusion: Inconsistent cuff pressure monitoring is done in the critical care environment. Comparing the continuous pressure monitoring, it shows that the frequency of monitoring need to be re-looked. Continuous in-service training may have an effect on the practice and the use of reminders can have an impact in the practice. Frequent clinical audits need to be conducted in order to evaluate practice and have plans for improvement. Clinical relevance: If the practice of tracheal cuff pressure monitoring can be done according to the revised guidelines, there might be an improved outcome of patients in the critical care environment and reduced costs.
Dissertation (MCur)--University of Pretoria, 2015.
Nursing Science
MCur
Unrestricted

INTRODUÇÃO: Diferentes parâmetros hemodinâmicos, incluindo os indicadores estáticos de pré-carga cardíaca como o índice de volume diastólico final ventrículo direito (IVDFVD) e parâmetros dinâmicos como a variação de pressão de pulso (VPP) têm sido usados na tomada de decisão para considerar o processo da expansão volêmica em pacientes em estado grave. O objetivo deste estudo foi comparar a reanimação por fluidos guiados tanto por VPP ou IVDFVD após choque hemorrágico induzido experimentalmente. MÉTODO: vinte e seis suínos anestesiados e ventilados mecanicamente foram alocados em três grupos: controle (Grupo I), VPP (Grupo II) e IVDFVD (Grupo III). Foi induzido choque hemorrágico por retirada de sangue até atingir a pressão arterial média de 40mmhg, que foi mantida por 60 minutos. Parâmetros foram medidos no tempo basal (B), no tempo do choque (Choque 0), sessenta minutos depois do choque (Choque 60), imediatamente depois da ressuscitação com hidroxietilamido 6% (130/0. 4) (R0), uma hora (R60) e duas horas (R120) depois ressuscitação. Os pontos de avaliação da reanimação por fluidos foram determinados pelo retorno aos valores basais iniciais de VPP e IVDFVD. A análise estatística dos dados foi baseada em ANOVA para medidas repetidas seguidos pelo teste de Bonferroni (P<0.05%). RESULTADOS: O volume e tempo para ressuscitação foram maiores no grupo III do que no grupo II (Grupo III = 1305±331ml e Grupo II = 965±245ml; p<0.05 e Grupo III = 24.8± 4.7min e Grupo II = 8.8 ± 1.3 min, p<0.01, respectivamente). Todos os parâmetros estáticos e dinâmicos, bem como os biomarcadores de oxigenação tecidual foram afetados pelo choque hemorrágico e quase todos os parâmetros foram totalmente restaurados após a reanimação em ambos os grupos. CONCLUSÃO: Neste estudo em modelo de choque hemorrágico, a reanimação guiada pelo VPP utilizou menor quantidade de fluido e menor quantidade de tempo do que quando guiado por IVDFVD derivado de cateter de artéria pulmonar.
INTRODUCTION: Different hemodynamic parameters, including static indicators of cardiac preload as right ventricular end-diastolic volume index (RVEDVI) and dynamic parameters as pulse pressure variation (PPV) have been used in the decision-making process regarding volume expansion in critically ill patients. The objective of this study was to compare fluid resuscitation guided by either PPV or RVEDVI after experimentally-induced hemorrhagic shock. METHODS: 26 anesthetized and mechanically ventilated pigs were allocated into control (Group-I), PPV (Group-II) and RVEDVI (Group- III). Hemorrhagic shock was induced by blood withdrawal to target mean arterial pressure of 40mmHg, maintained for 60 minutes. Parameters were measured at baseline, time of shock, sixty minutes after shock, immediately after resuscitation with hydroxyethyl starch 6% (130/0.4), one hour and two hours thereafter. The endpoint of fluid resuscitation was determined as the baseline values of PPV and RVEDVI. Statistical analysis of data was based on ANOVA for repeated measures followed by the Bonferroni test (P<0.05). RESULTS: Volume and time to resuscitation were higher in Group-III than in Group-II (Group-III = 1305±331ml and Group-II = 965±245ml; p<0.05 and Group-IIII = 24.8±4.7min and Group-II = 8.8±1.3 min, p<0.05, respectively). All static and dynamic parameters and biomarkers of tissue oxygenation were affected by hemorrhagic shock and nearly all parameters were restored after resuscitation in both groups. CONCLUSION: In the proposed model of hemorrhagic shock, resuscitation to the established endpoints was achieved within a smaller amount of time and with less volume when guided by PPV than when guided by pulmonary artery catheter-derived RVEDVI.

Introdução: Eventos adversos a medicamentos (EAM) representam um importante problema de saúde pública, sendo associados à morbimortalidade, maior taxa de permanência hospitalar e elevação de custos. Os idosos e os pacientes de unidade de terapia intensiva (UTI) são grupos de risco para a ocorrência desses eventos. O uso de rastreadores, que representam situações indicativas de potenciais EAM, simplifica a detecção de EAM por meio do screening sistemático de prontuários, possibilitando a mensuração da taxa dessas adversidades continuamente e permitindo avançar na prática de segurança do paciente crítico. Objetivo: Analisar os eventos adversos a medicamentos e fatores associados em pacientes idosos de UTI. Método: Coorte retrospectiva conduzida com idosos internados em UTI do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A amostra consecutiva foi composta por prontuários de idosos, hospitalizados por no mínimo 24 horas para tratamento clínico ou cirúrgico e que tenham recebido pelo menos um medicamento. Os pacientes foram acompanhados da internação até a saída da UTI por alta ou óbito. Para a identificação dos EAM utilizou-se o instrumento do Institute for Healthcare Improvement (IHI) adaptado para a realidade local, que inclui rastreadores medicamentosos, bioquímicos e clínicos. Foram coletadas variáveis demográfico-clínicas, relativas ao regime terapêutico, exames laboratoriais, intervenções durante a internação e sinais/sintomas clínicos. A variável dependente foi a ocorrência de EAM. Os dados foram analisados por meio dos testes Qui-quadrado, Exato de Fisher, Correlação de Pearson e regressão logística multivariada, com significância de p0,05. Resultados: A incidência de pacientes com EAM foi 22,3% e o número de EAM por 100 pacientes foi 32,3, média de 1,4 EAM. A amostra foi composta predominantemente por homens (54,6%), idosos jovens (68,8%), internados para procedimentos clínicos (67,4%) e sujeitos a polifarmácia (70,6%). Sangramento (21,7%), injúria renal aguda (20%), hipotensão (18,3%), náusea/vômito (15%) e hipoglicemia (13,3%) foram os EAM mais frequentes. Identificou-se correlação positiva entre EAM e as variáveis comorbidades (r=0,189), tempo de internação (r=0,288) e número de medicamentos prescritos (r=0,282). Os fatores de risco para EAM em UTI foram ventilação mecânica (OR= 2,614; IC95% 1,393 4,906; p= 0,003), injúria renal aguda (OR= 3,794; IC95% 1,688 8,527; p=0,001) e diabetes mellitus (OR= 3,280; IC 95% 1,703 6,315; p= 0,000). Conclusão: A ocorrência dos EAM mostrou-se correlacionada positivamente com atributos que são muito característicos de idosos admitidos em UTI, aspecto que pode servir de alerta aos profissionais que realizam o monitoramento desses eventos.
Introduction: Adverse drug events (ADE) represent an important public health problem, being associated with morbidity and mortality, a higher hospital stay rate and higher costs. The elderly and intensive care patients (ICU) are at risk groups for the occurrence of these events. The use of trackers, which represent situations indicative of potential ADE, simplifies the detection of ADE through the systematic screening of medical records, making it possible to measure the rate of these adversities continuously and to advance in the practice of critical patient safety. Objective: To analyze adverse drug events and associated factors in elderly ICU patients. Method: Retrospective cohort conducted with elderly patients admitted to ICU at Hospital das Clínicas, Medical School, University of São Paulo. The consecutive sample consisted of records of the elderly, hospitalized for at least 24 hours for clinical or surgical treatment and who received at least one medication. Patients were followed up for ICU discharge or discharge. The Institute for Healthcare Improvement (IHI) instrument adapted to the local reality, which includes drug, biochemical and clinical trackers, was used to identify the ADE. Demographic and clinical variables related to the therapeutic regimen and laboratory tests, therapeutic interventions during hospitalization, clinical signs and symptoms were collected. The dependent variable was the occurrence of ADE. Data were analyzed using the Chi-square test, Fisher\'s exact test, Pearson\'s correlation and multivariate logistic regression, with significance of p0.05. Results: The incidence of ADE patients was 22.3% and the number of ADE per 100 patients was 32.3, a mean of 1.4 ADE. Men (54.6%), young adults (68.8%), hospitalized for clinical procedures (67.4%) and polypharmacy (70.6%). Bleeding (21.7%), acute renal injury (20%), hypotension (18.3%), nausea / vomiting (15%) and hypoglycaemia (13.3%) were the most frequent events. A positive correlation between EAM and comorbidities (r = 0.189), length of hospital stay (r = 0.288), and number of drugs prescribed (r=0.282) were identified. The risk factors for EAM in the ICU were mechanical ventilation (OR= 2,614; IC95%, 1,393 4,906; p= 0,003), acute renal injury (OR= 3,794; IC95% 1,688 8,527; p=0,001) and diabetes mellitus (OR= 3,280; IC 95% 1,703 6, 315; p= 0,000). Conclusion: The occurrence of ADE was positively correlated with attributes that are very characteristic of the elderly admitted to the ICU, an aspect that can serve as an alert to the professionals who perform the monitoring of these events.

Dissertation (Ph.D.)--University of Toledo, 2010.
Typescript. "Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Doctor of Philosophy Degree in Engineering." "A dissertation entitled"--at head of title. Title from title page of PDF document. Bibliography: p. 191-212.

The dependence of cardiac output measurement precision on ambient temperature and cardiac output stability was assessed by concurrent continuous and bolus thermodilution methods in postoperative cardiac surgery patients. The degree of agreement between the two methods was depended on room temperature (0.1 L/min for each degree below 25 degrees C). The agreement was also closer in trials where cardiac output was stable (< 10% variation). The continuous thermodilution method shows sufficient agreement with the bolus method for use in critical care; however, improved precision of cardiac output thermodilution measurements can be achieved by use of correction factors for cardiac instability and for ambient temperature.

Critically ill patients often exhibit abnormal glycaemia that can lead to severe complications and potentially death. In critically ill adults, hyperglycaemia is a common problem that has been associated with increased morbidity and mortality. In contrast, critically ill infants often suffer from hypoglycaemia, which may cause seizures and permanent brain injury. Further complicating the matter, both of these conditions are diagnosed by blood glucose (BG) measurements, often taken several hours apart, and, as a result, these conditions can remain poorly managed or go completely undetected. Emerging ‘continuous’ glucose monitoring (CGM) devices with 1-5 minute measurement intervals have the potential to resolve many issues associated with conventional intermittent BG monitoring. The objective of this research was to investigate and develop methods and models to optimise the clinical use of CGM devices in critically ill patients. For critically ill adults, an in-silico study was conducted to quantify the potential benefits of introducing CGM devices into the intensive care unit (ICU). Mathematical models of CGM error characteristics were implemented with existing, clinically validated, models of the insulin-glucose regulatory system, to simulate the behaviour of CGM devices in critically ill patients. An alarm algorithm was also incorporated to provide a warning at the onset of predicted hypoglycaemia, allowing a virtual dextrose intervention to be administered as a preventative measure. The results of the in-silico study showed a potential reduction in nurse workload of approximately 75% and a significant reduction in hypoglycaemia, while also providing insight into the optimal rescue dose size and resulting dynamics of glucose recovery. During 2012, ten patients were recruited into a pilot clinical trial of CGM devices in critical care with a primary goal of assessing the reliability of CGM devices in this environment, with a specific interest in the effects of CGM device type and sensor site on sensor glucose (SG) data. Results showed the mean absolute relative difference of SG data across the cohort was between 12-24% and CGM devices were capable of monitoring some patients with a high degree of accuracy. However, certain illnesses, drugs and therapies can potentially affect sensor performance, and one particular set of results suggested severe oedema may have affected sensor performance. A novel and first of its kind metric, the Trend Compass was developed and used to assesses trend accuracy of SG in a mathematically precise fashion without approximation, and, importantly, does so independent of glucose level or sensor bias, unlike any other such metrics. In this analysis, the trend accuracy between CGM devices was typically good. A recent hypothesis suggesting that glucose complexity is associated with mortality was also investigated using the clinical CGM data. The results showed that complexity results from detrended fluctuation analysis (DFA) were influenced far more by CGM device type than patient outcome. In addition, the location of CGM sensors had no significant effect on complexity results in this data set. Thus, while this emerging analytical method has shown positive results in the literature, this analysis indicates that those results may be misleading given the impact of technology outweighing that of physiology. This particular result helps to further delineate the range of potential applications and insight that CGM devices might offer in this clinical scenario. In critically ill infants, CGM devices were used to investigate hypoglycaemia during the first 48 hours after birth. More than 50 CGM data sets were obtained from several studies of CGM in infants at risk of hypoglycaemia at the Waikato hospital neonatal ICU (NICU). In light of concerns regarding CGM accuracy, particularly during the first few hours of monitoring and/or at low BG levels, an alternative, novel calibration scheme was developed to increase the reliability of SG data. The recalibration algorithm maximised the value of very accurate calibration BG measurements from a blood gas analyser (BGA), by forcing SG data to pass through these calibration BG measurements. Recalibration increased all metrics of hypoglycaemia (number, duration, severity and hypoglycaemic index) as the factory CGM calibration was found to be reporting higher values at low BG levels due to its least squares calibration approach based on the assumption of a less accurate calibration glucose meter. Thus, this research defined new calibration methods to directly optimise the use of CGM devices in this clinical environment, where accurate reference BG measurements are available. Furthermore, this work showed that metrics such as duration or area under curve were far more robust to error than the typically used counted-incidence metrics, indicating how clinical assessment may have to change when using these devices. The impact of errors in calibration measurements on metrics used to classify hypoglycaemia was also assessed. Across the cohort, measurement error, particularly measurement bias, had a larger effect on hypoglycaemia metrics than delays in entering calibration measurements. However, for patients with highly variable glycaemia, timing error can have a significantly larger impact on output SG data than measurement error. Unusual episodes of hypoglycaemia could be successfully identified using a stochastic model, based on kernel density estimation, providing another level of information to aid decision making when assessing hypoglycaemia. Using the developed algorithms/tools, with CGM data from 161 infants, the incidence of hypoglycaemia was assessed and compared to results determined using BG measurements alone. Results from BG measurements showed that ~17% of BG measurements identified hypoglycaemia and over 80% of episodes occurred in the first day after birth. However, with concurrent BG and SG data available, the SG data consistently identified hypoglycaemia at a higher rate suggesting the BG measurements were not capturing some episodes. Duration of hypoglycaemia in SG data varied from 0-10+%, but was typically in the range 4-6%. Hypoglycaemia occurred most frequently on the first day after birth and an optimal measurement protocol for at risk infants would likely involve CGM for the first week after birth with frequent intermittent BG measurements for the first day. Overall, CGM devices have the potential to increase the understanding of certain glycaemic abnormalities and aid in the diagnosis/treatment of other conditions in critically ill patients. This research has used a range of prospective and retrospective clinical studies to develop methods to further optimise the use of CGM devices within the critically ill clinical environment, as well as delineating where they are less useful or less robust. These latter results clearly define areas where clinical practice needs to adapt when using these devices, as well as areas where device makers could target technological improvements for best effect. Although further investigations are required before these devices are regularly implemented in day-to-day clinical practice, as an observational tool they are capable of providing useful information that is not currently available with conventional intermittent BG monitoring.

South Africa is faced with enormous backlog of service delivery which is attributed to the apartheid government and performance challenges especially in areas like Eastern Cape. It was then identified that there was no uniform system to monitor and evaluate performance of government institutions and the impact of the services they render to the community. The government then adopted a monitoring and evaluation system called Government - Wide Monitoring and Evaluation System for all government departments and municipalities. This study analysed the implementation of this Government-Wide Monitoring and Evaluation System in Eastern Cape Municipalities with specific reference to Chris Hani District Municipality. It further assessed the effectiveness of this monitoring and evaluation system and whether its implementation has improved performance in municipalities, so as to identify the hampering limitations and the appropriate improvement strategies that can be recommended. In order to reach conclusions to the questions and objectives, the study was conducted using qualitative research methodology. Interviews were conducted as described in chapter 3. Chapter 4 presents the findings that were achieved from the interviews and the interpretation of these findings whilst chapter 5 presents conclusion and recommendations based on the findings.

This study seeks to assess the level of women&rsquo
s participation and involvement in the promotion of effective governance during the African Peer Review Mechanism (APRM) implementation exercise in 2007, which was endorsed by the APRM Western Cape Province. The interest of the study arises from the concept of &lsquo
good governance&rsquo
and how the implementation of such a concept is carried out in the rendering of public services, specifically the role of women in rendering public service in the Western Cape Province, South Africa.

碩士
國立屏東科技大學
資訊管理系所
100
With the improvement in medical infrastructure and technology, the ageing phenomenon in Taiwan becomes more and more seriously. The health care issue in critical ill patients is being taken with severe attention. Because the physical condition on critical ill patients is worse than mild disease patients, they are more pressing needs for monitoring if the care staff cannot always beside of them. The patients only can use the emergency button passively to inform nursing station when they feel not good or have abnormal condition, but some critical ill patients cannot talk or their hands cannot move so that this study highlights the importance of health care support system. This study is to build a health care system for critically ill patients, and it provides two functions to user. First is abnormal function of facial expression recognition which can recognize patients’ facial expressions. When the system recognizes patient showed abnormal expression, it will send a warning message to the nursing station and record it in the database in order to do the analysis application. The second is gesture recognition for patients' needs. The system will send a message to the nursing station when the patients make a specific gesture. We can use video monitoring devices and image recognition technology to determine whether the patient is in a normal condition or not and to inform the care staff in order to reach the goal of assist the care staff and ease their burden.

This thesis presents a framework for the deployment of algorithms that support the correlation and real-time classification of physiological data streams through the development of clinically meaningful alerts using a blend of expert knowledge in the domain and pattern recognition programming based on clinical rules. Its relevance is demonstrated via a real world case study within the context of neonatal intensive care to provide real-time classification of neonatal spells. Events are first detected in individual streams independently; then synced together based on timestamps; and finally assessed to determine the start and end of a multi-signal episode. The episode is then processed through a classifier based on clinical rules to determine a classification. The output of the algorithms has been shown, in a single use case study with 24 hours of patient data, to detect clinically significant relative changes in heart rate, blood oxygen saturation levels and pauses in breathing in the respiratory impedance signal. The accuracy of the algorithm for detecting these is 97.8%, 98.3% and 98.9% respectively. The accuracy for correlating the streams and determining spells classifications is 98.9%. Future research will focus on the clinical validation of these algorithms and the application of the framework for the detection and classification of signals in other clinical contexts.

Failure to recognize and respond to changes in a patient’s condition is a limitation in the effective utilization of Medical Emergency Teams (METs). A system that uses smartphone technology to facilitate vital signs collection at bedside has been developed. The alerts engine, based upon Mount Sinai Hospital’s (MSH) MET calling criteria, can automatically alert the MET of patients exhibiting abnormal vital signs. The system, without automated alerting, was piloted at MSH. Sensitivity and specificity calculations revealed that the MSH algorithm had a lower sensitivity and specificity than the Cuthbertson or the Modified Early Warning Score algorithms. This suggests that the MSH algorithm, compared to the others, was poor at identifying patients that did and did not require a MET consultation. Furthermore, the low positive predictive value suggests that the majority of alerts were not associated with a MET call. Therefore, the MSH algorithm is not recommended for the automated system.

Background: The neurological examination in critically ill patients is limited due to decreased level of consciousness and sedating medications. Electroencephalography (EEG) can be used to monitor brain injury; however, availability is limited. Methods: To determine the perceived need for EEG monitoring in the ICU and its current availability, we used rigorous methodology to develop and disseminate a survey to 199 Canadian critical care physicians. Results: Of 103 (52%) respondents (77% academic practice; 83% adult focus), 75% stated EEG monitoring should be a standard of care; yet, 75.5% were unable to obtain an EEG in an optimal timeframe. Technology under-use was exacerbated during non-standard working hours and greater in adult institutions. Perceived barriers to optimal care were lack of EEG technicians, physicians to interpret EEG and finances. Conclusion: Sub-optimal availability of EEG represents an important gap in the care of neurologically injured patients. Specific barriers represent targets for quality improvement.

碩士
國立臺灣大學
光電工程學研究所
97
In intensive care unit (ICU) the condition of patients were instable. The patients were observed with much physiological information about heart rate, blood pressure, body temperature, SpO2 to diagnosis the condition of patients in time. A system with fast, noninvasive, portable, low cost and without radiation was developed to be a bedside monitor system. Diffuse optical image system with continuous wave laser diode and photodiode on flexible black rubber was designed to obtain information of oxy-hemoglobin, deoxy-hemoglobin, total hemoglobin and tissue oxygen saturation. In this thesis, the difference of venous occlusion hemodynamics are observed in vivo measurements form normal subjects, patients with heart failure and sepsis in intensive care unit. On the other hand, for further understanding of basic physiological signification from diffuse photon measurements, the arterial occlusion hemodynamics are related to the elasticity of red blood cell in experiments.

Introduction: Outcome prediction tools have the potential to provide significant adjunctive information for intensivists. Critically ill obstetric and gynaecology patients constitute a unique subset of the general ICU (intensive care unit) population yet, there exists no outcome prediction model developed specifically for these patients. Objectives: To evaluate the APACHE II score, prospectively develop and validate an outcome prediction model, evaluate organ failure (Organ Failure score and SOFA score) and review the SIRS (Systemic Inflammatory Response Syndrome) response in a cohort of critically ill obstetric and gynaecology patients. Design: A prospective study conducted over a 2 year period in the Surgical ICU at King Edward VIII Hospital, Durban. Institutional ethics approval was obtained. Patients were allocated to one of the following categories: Obstetric hypertensive group (Group I), Obstetric non-hypertensive group (Group II) and Gynaecology group (Group III). Group III was further subdivided into a pregnant (Group IIIa) and a non-pregnant group (Group IIIb). Data captured included demographic details, clinical assessment, investigations, treatment, variables required for calculating the APACHE II score, organ failure (OF) assessment, SIRS criteria and patient outcome. The APACHE II system, organ failure assessment and SIRS was evaluated in the entire patient subset. For the purpose of the outcome prediction model, the subset was divided into 2 groups: a development group and a validation group. STATA 7 software was utilised for data analysis. Results: The dataset comprised 260 inpatients. Obstetrics and gynaecology cases represented 18.5 % of the total ICU population (n=1408). The majority of the patients were young (mean age 27 ± 10.5 years). The mean ICU stay was 5.5 ± 7.9 days. The observed mortality for Groups I, II, III, IIIa and IIIb was 23.4%, 43.2%, 42.9%, 33.3% and 55.5% respectively. The mean APACHE II score was significantly higher in nonsurvivors compared to survivors for all patient subgroups (p< 0.0001). However the APACHE II system performed variably in each of the 3 groups. The area under the curve for the ROC curves in each of the 3 main subgroups varied from 0.81 to 0.94 for APACHE II. Groups IIIa and IIIb were too small to permit ROC curve analysis. Age, mean arterial pressure, respiratory rate, temperature, the Glasgow Coma Scale score and pH were identified as significant outcome predictors. Using these parameters an obstetric and gynaecology outcome prediction (OGOP) model was developed for Groups I, II and III. The area under the curve for the ROC curves in each of the subgroups was >0.9 for the OGOP Model. A predictive equation could not be developed for Groups IIIa and IIIb (due to a small number of admissions in these two groups.) Duration and the number of organ failures, correlated with outcome. The duration and number of organ failures associated with mortality differed for each group. Three OF exceeding 72 hours, 3 OF exceeding 48 hours and 3 OF equal to 48 hours were invariably fatal in Groups I, II and III/IIIa/IIIb respectively. SOFA scores were significantly higher in nonsurvivors compared to survivors (p<0.0001). A day one SOFA score equal to 18 (Group I), 15 (Group ll) and 13 (Group III, IIIa, IIIb) was also invariably fatal. A SIRS response was noted in 94.2% of the patient cohort (245/260). The SIRS response varied in the subgroups. Sterile shock and septic shock were associated with a high mortality rate. Groups IIIa and IIIb differed with respect to the mean age, duration of hospital and ICU stay and mortality rate. Although these subsets were numerically restricted (24 and 18 admissions respectively), the results suggest that the two subsets are distinctly different in nature. Comment: The OGOP model is easier to calculate and it is superior to the APACHE II System. It needs to be validated in other local and international units. Organ failure assessment as well as the SIRS response provides useful supplementary outcome information. Although current outcome prediction tools are not designed for individual application, continued research and refinement of the available tools, as well as the exploration of novel methods, may one day result in "near-perfect" prediction estimates and further broaden the scope of their utility.
Thesis (Ph.D)-University of KwaZulu-Natal, 2006.

In-patient deterioration is a global phenomena and timely recognition and action improves outcome. Intensive care facilities are scarce and expensive and therefore patient care must be optimal. A retrospective health record analysis was used for this study. The findings indicated that nursing personnel do not recognize patient deterioration timeuously. However, the implementation of an outreach team and clinical markers training program improved the recognition of patient deterioration in general wards with three hours and 40 minutes. It is recommended to implement a comprehensive hospital program that addresses the basic knowledge and skills of general ward personnel to observe, recognize, assess and intervene to patients with clinical deterioration. Together with an extensive training program, a basic physiological parameters guideline to activate a team of experts to the bedside, such as an Outreach team, assist nursing personnel to recognize and manage those patients timeuously and ensure treatment in an appropriate level of care.
Health Studies
M. A. (Health studies)

Beneš J.: HEMODYNAMIKA V ČASNÉ FÁZI KRITICKÝCH STAVŮ A PERIOPERAČNÍ MEDICÍNĚ - Využití méně invazivních monitorovacích prostředků k cílené hemodynamické péči ABSTRACT Hemodynamic instability occurs very often in critically ill patients and during the perioperative period. Insufficiency in the preload, contractility and afterload contribute in major part to this phenomenon. Hemodynamic monitoring allows clinicians to recognize and to intervene early the underlying cause. Due to new technologies development in recent years it is possible to provide continuous monitoring of hemodynamic parameters with diminished invasivity. Hemodynamic optimization and goal directed therapy show treatment benefit in some groups of critically ill patients and mainly during the perioperative period. Aim of hemodynamic optimizations is to attain the best obtainable hemodynamic conditions with use of fluid loading and inotropic support. In many studies in recent years goal-directed therapy was associated with morbidity and mortality reduction. According to the results of our clinical research hemodynamic optimization using stroke volume variation and minimally invasive device based on the pressure wave analysis is feasible and show the same results as other works with more invasive devices. Key words Hemodynamic monitoring,...