Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2009
ReviewComputerized physician order entry in critical care.
Computerized physician order entry means prescribing of medication and ordering laboratory tests or radiology examinations in an electronic way instead of using paper forms. In itself, it offers advantages such as legible orders, faster order completion, inventory management and automatic billing. If combined with clinical decision support, the real benefits of CPOE become apparent in the first place by prevention of medication errors and adverse drug events. ⋯ Therefore, and for reasons of end-user acceptance, implementation is challenging. CPOE has the potential for significant economic saving. However, the initial implementation cost is high.
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Variation in clinical practice impedes control, is associated with unwanted and widespread error, and may preclude replicability. Methodologic replicability enhances our ability to detect signals of interest by both increasing the signal through consistent application of the intervention, and by reducing the obscuring effects of noise. Decision-support tools are intended to standardize some aspect of clinical care and thereby help lead to uniform implementation of clinical interventions. ⋯ Development of such protocols has required around-the-clock implementation for patient management because of the influence of patient history and previous patient states on the output of the computer protocol. Three successful computer protocols for management of blood glucose provide compelling examples. This clinician driven "bottom-up" approach complements the common information technology service driven "top-down" approach to clinical problems.
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Blood glucose control performed by intensive care unit (ICU) nurses is becoming standard practice for critically ill patients. New algorithms, ranging from basic protocols to elementary computerized protocols to advanced computerized protocols, have been presented during the last years aiming to reduce the workload of the medical team. ⋯ Particularly advanced computerized protocols can potentially be introduced as fully-automated blood glucose algorithms when accurate and reliable near-continuous glucose sensor devices are available. Furthermore, it is surprising to consider in some of the described protocols that the original blood glucose target ranges (80-110 mg/dl) were increased (due to fear of hypoglycaemia) and/or that glycaemia levels were determined in capillary blood samples.
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Best Pract Res Clin Anaesthesiol · Mar 2009
ReviewMachine learning techniques to examine large patient databases.
Computerization in healthcare in general, and in the operating room (OR) and intensive care unit (ICU) in particular, is on the rise. This leads to large patient databases, with specific properties. ⋯ Although the number of potential applications for these techniques in medicine is large, few medical doctors are familiar with their methodology, advantages and pitfalls. A general overview of machine learning techniques, with a more detailed discussion of some of these algorithms, is presented in this review.
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Best Pract Res Clin Anaesthesiol · Mar 2009
ReviewClosed-loop control for intensive care unit sedation.
The potential clinical applications of active control for pharmacology in general, and anesthesia and critical care unit medicine in particular, are clearly apparent. Specifically, monitoring and controlling the depth of anesthesia in surgery and the intensive care unit is of particular importance. Nonnegative and compartmental models provide a broad framework for biological and physiological systems, including clinical pharmacology, and are well suited for developing models for closed-loop control for drug administration. ⋯ Closed-loop control based on appropriate dynamical systems models merits investigation as a means of improving drug delivery in the intensive care unit. In this article, we discuss the challenges and opportunities of feedback control using nonnegative and compartmental system theory for the specific problem of closed-loop control of intensive care unit sedation. Several closed-loop control paradigms are investigated including adaptive control, neural network adaptive control, optimal control, and hybrid adaptive control algorithms for intensive care unit sedation.