Current issues in healthcare
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Current issues in healthcare 2. Neonatal apnea Centre for Doctoral Training in Healthcare Innovation. Dr. Gari D. Clifford, University Lecturer & Associate Director, Centre for Doctoral Training in Healthcare Innovation, Institute of Biomedical Engineering, University of Oxford.

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Dr. Gari D. Clifford, University Lecturer & Associate Director,

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Dr gari d clifford university lecturer associate director

Current issues in healthcare2. Neonatal apneaCentre for Doctoral Training in Healthcare Innovation

Dr. Gari D. Clifford,

University Lecturer & Associate Director,

Centre for Doctoral Training in Healthcare Innovation,

Institute of Biomedical Engineering,

University of Oxford


Current icu monitoring systems

Current ICU Monitoring Systems

Single & independent signal processing

ECG (several leads), ABP, PAP, PLETH, RESP, etc....

Alarms issued when values cross “normal” thresholds

Color-coded (RED, YELLOW, GREEN) alarms indicate case severity

Cannot robustly distinguish between alarms caused by

Physiologic changesand

Noise, artifacts, data loss, monitor algorithm errors


The problem

The Problem

High ICU False Alarm (FA) Rates:

Broad disruption of care, impacting both

patients & clinical staff.

Alarms can produce noises > 80 dB:

Patient sleep deprivation

Stress for both patients and staff

FA rates can be as high as 86%(Lawless, 1994):

Desensitization of the clinical attending staff

Delayed response times and confusion

Ignored or missed critical alarms


Phenomenology of apnea

Phenomenology of apnea

Often accompanied by:

Bradycardia (a heart rate less than 100 beats per minute in neonates and 50 beats per minute in adults),

Cyanosis, or pallor (due to oxygen desaturation).

Decrease in peripheral blood flow

EEG changes suggesting CNS depression if apnea is severe

Increase in venous pressure

Decrease in muscle tone


Biggest problem alarm in icu

Biggest problem alarm in ICU

Most common life-threatening alarm in the ICU is apnea (breathing stops)

Monitor recording no respiratory waveform and concluding that an apnea (cessation of inspiratory gas flow for 20 seconds)


Current situation

Current situation

To accurately detect episodes of apnea, bradycardia, and desaturation leading to hypoxia, or ‘spells’, human oversight is required to piece together the sequence of events, which are recorded on separate monitors that do not exchange information.

Even then, many spells can be missed due to sensor artifact.

Oxygen saturation & respiratory signals known to be extremely noisy

Masks many true alarms and leads to many false alarms.

The cost of missing or delaying reaction to apneas can be as severe as multi-organ damage and can lead to prolonged patient stays and poorer outcomes.


Apnea associated clinical problems

Apnea-associated clinical problems

Respiratory Distress Syndrome

Pulmonary mechanical problems such as Airleak, or Atelectasis

Infectious causes such as Sepsis, Meningitis, or Pneumonia

Intracranial Hemorrhage

Seizures

Anemia

Gastroesophageal Reflux

Necrotizing Enterocolitis

Patent Ductus Arteriosus

Hemorrhagic Shock

Metabolic disturbances such as Hypoglycemia, Acidosis, Hyponatremia, Hypocalcemia

Inappropriate Thermal Environment - Hyperthermia


What can we do to improve this

What can we do to improve this?

Improve apnea detector sensitivity

(fewer false alarms)

Improve apnea detector positive predictivity

(fewer missed true alarms)

Detect apneas before desaturation


References

References

Nicu Web:http://depts.washington.edu/nicuweb/NICU-WEB/apnea.stm

Aboukhalil, A., Nielsen, L., Saeed, M., Mark, R.G., Clifford, G.D., Reducing False Alarm Rates for Critical Arrhythmias using the Arterial Blood Pressure Waveform, Journal of Biomedical Informatics, Special Issue on Computerized Decision Support for Critical and Emergency Care, Volume 41, Issue 3, June 2008, pp 442-451, http://www.mit.edu/%7Egari/papers/fasup1.pdf

Richard J. Martin, and Christopher G. Wilson What to do about apnea of prematurity?J Appl Physiol 107: 1015-1016, 2009. http://jap.physiology.org/cgi/content/full/107/4/1015


Biggest problem alarm in icu1

Biggest problem alarm in ICU

Most common life-threatening alarm in the ICU is apnea (breathing stops)

Monitor recording no respiratory waveform and concluding that an apnea (cessation of inspiratory gas flow for 20 seconds)


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