|
From Good to Better: Critical Care
Technology has permeated every aspect of critical care
Dr KJ Choudhury |
Intensive care is nothing but intensive monitoring. We have
come a long way from recording clinical vital signs like pulse, blood pressure
(BP), temperature and respiration and now pain as the fifth vital sign. Technology
has permeated in almost every aspect and critical care is no exception. Everything
could be done manually, but soon it was discovered that we need advanced technologies
to replace the old ideas. Some of these monitoring technologies were used in
the operating theatre and they were extended to the ICU. Very soon, it was realised
that critically ill patients require continuous and effective monitoring of
all vital signs which was considered impossible a few years earlier. The sense
of urgency created by critically ill patients combined with readily visible
success and failure drives the quest for improved monitoring and therapeutic
tools. We shall discuss some of these developments briefly.
Area of Diagnostics
Point-of-care (POC) testing refers to the performance of diagnostic tests at
either directly at the patient's bedside or in a 'mini' or 'stat' laboratory
within the ICU setting. Therapeutic Turn-Around Time (TTAT) is the time between
ordering the tests to the implementation of the actions generated by the results.
Multi-step central laboratory programme leads to long delays and may not keep
pace with the dynamically evolving clinical needs of the unstable, critically
ill patient and often had to be repeated because of error in sampling, labeling,
or inadequate sampling. When laboratory results arrive at the ICU, they reflect
the past and not the patient's present condition. These can definitely change
the outcome of the critically sick patients with rapidly changing internal milieu.
Analysis of serum electrolytes is an example, reports of which, if not available
immediately, will be useless in terms of replacement therapy. A haemodynamically
unstable patient loses consciousness within ten seconds of oxygen (O2) deprivation
and within six minutes permanent brain damage can result due to drained creatine
phosphate and adenosine triphosphate (ATP) energy reserves. With the availability
of bedside multi-analysers, critical care profile (CCP) should suggest whether
tissues are receiving adequate oxygen or not, and why the availability has been
compromised.
Today, technological advancement characterised by microchemistry, micro computerisation,
miniaturisation and non-invasive testing has revolutionised the concept of present
day laboratories. A blood monitor can be used ex vivo or in vivo. Ex vivo technologies
use specimen that are drawn from the patient and analysed outside the body,
with some of them allowing the return of the specimen to the patient. In vivo
technologies provide the opportunity to measure pH, blood gases, electrolytes,
lactate, and glucose levels directly, gastric intramucosal pH, with the help
of invasive sensors. Advanced IT systems also are playing an increasingly important
role. POC testing, by making test results rapidly available to clinical information
systems through electronic patient records. With the ever decreasing blood sample
requirements for analysis, microsample POC devices can have a great impact on
blood conservation.
Integration of IT with ICU
Physiological signals are complex and noisy and patients respond to therapies
in highly individual ways. Hence, the challenges of improved continuous monitoring
remain. Enormous amount of data is created in ICU from ventilators to assist
breathing, intravenous (IV) lines for fluids, medications and nutrition, and
a multitude of monitors, most of them controlled by small but powerful computers
and from large variety of laboratory studies and imaging. IT makes it possible
to automatically collect, process, retrieve, analyse patient data from variety
of equipment and sources that will help improve clinical decision, productivity
as well as reduce medical errors. Taking efficiency in monitoring trends, computer
decision support technique has been devised resulting in a reduction in false
positive alarms and time required for correct diagnosis of life threatening
conditions in the ICU.
| Currently, the vital sign monitors tell the intensivists
about the critical changes that have already occurred. Future intelligent
monitors will be able to warn the caregivers much ahead of occurrence of
actual critical events. The monitor would in fact be able to sense warning
of critical events rather than present. Continuous monitoring of changes
occurring at cellular level in a critically ill patient is feasible today.
Developments are occurring in this area like brain O2 monitor. Trends of
monitoring are more in favor of non-invasive techniques which will eliminate
cumbersome invasive procedure that requires lot of skills.
Target-oriented drug delivery systems are being
developed to reduce both, dose and toxicity of potent drugs. Some of the
systems delivering drugs like insulin can adjust the dose by sensing blood
glucose level.
Life-saving equipment is being developed which are sensitive
to changes in patient's vital functions and automatically adjusts the
settings according to patient needs. Many of mechanical ventilators today
are already patient sensitive.
Like any other field of science the technology used in
critical care medicine is evolving very fast. So the person/ man behind
the machine must keep pace with latest development and provide feedback
for continuous improvement.
|
Interpretation of information overload may be time consuming and error prone.
On the other hand, the richness and details of data could be of immense help
to the clinicians through systems that translate medical device data into industry
standard formats that can communicate with modern clinical information systems.
This can even replace all paper forms by an electronic equivalent, resulting
in a paperless ICU.
There is also the need for these processed data to be available to the physician
anywhere, both inside and outside the hospital through software that supports
bi-directional sharing of medical information between patients and physicians.
As matter of fact, softwares are available that enables the physician to access
real time patient data from anywhere who further can issue necessary instruction
to the immediate care givers using two way communications.
The writer is Senior Consultant Neuroanesthesiology & Pain
Management Indraprastha Apollo Hospital New Delhi
E-mail: kjchoudhury@samvedana.org
|
