continuous monitoring: state of the art &&&& pointpoint ...€¦ · the right tool...
TRANSCRIPT
ContinuousContinuousContinuousContinuous monitoring: monitoring: monitoring: monitoring:
state of the artstate of the artstate of the artstate of the art
&&&&
POCT symposium Antwerp 23 X 2014POCT symposium Antwerp 23 X 2014POCT symposium Antwerp 23 X 2014POCT symposium Antwerp 23 X 2014
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pointpointpointpoint----ofofofof----view view view view
of the anesthesiologist of the anesthesiologist of the anesthesiologist of the anesthesiologist
Dirk HimpeDirk HimpeDirk HimpeDirk Himpe MD PhD MHE EDICMD PhD MHE EDICMD PhD MHE EDICMD PhD MHE EDIC
What came first:
Administering Anaesthesia
16.X.1846
Administering Anaesthesia
or
Continuous Monitoring ?
anesthesiology
=
being there (point-of-care)
=
continuous continuous interaction:
MonitoringMonitoring
&
Titrating Anaesthetics/Drugs
proof ofproof of
vigilance & vigilance &
interactioninteraction
==
outcome outcome
monitors per senever
saved
anyone’s life …
a fool with a tool
is still a fool
State of the art ?!State of the art ?!State of the art ?!State of the art ?!State of the State of the State of the State of the
1° - a plea
for not using every available technology
and all last fashion devices on the market:
the right tool the right tool -- at the right time at the right time -- in the right place (POC)in the right place (POC);
2°- a paradigm
State of the art :State of the art :State of the art :State of the art :
2°- a paradigm
smart selection of diagnostic and monitoring
tools using theoretical concepts and frames (EB);
3°- health economy issues
C/E ratio & Value Based Purchasing;
1) Does the new tool agree with the Goldoldoldolden Standard?
(correlation analysis & Bland-Altman methodology)
2) Does it give the best information, which is not otherwise
available?
EB EB EB EB monitoringmonitoringmonitoringmonitoring////diagnosticdiagnosticdiagnosticdiagnostic technologytechnologytechnologytechnology assessmentassessmentassessmentassessment::::
3) Does the clinician may alter his
a. decision making
b. therapy
because of it ?
4) Does the patient do better (outcome)?
SIBBALD WJ, Clinical Chemistry, 36, 8:1604SIBBALD WJ, Clinical Chemistry, 36, 8:1604SIBBALD WJ, Clinical Chemistry, 36, 8:1604SIBBALD WJ, Clinical Chemistry, 36, 8:1604----11 (1990) 11 (1990) 11 (1990) 11 (1990)
first step:
plot of the results of one method against those of the other
correlation & regression
second step:
plot of the difference between the methods against
their mean (best guess):
Altman & Bland methodology (Lancet 1986):
their mean (best guess):
A&B plot -> bias, precision & limits of agreement
third step:
exclude the existence of any linear relationship between differences and
averages to prove that the differences between both methods are
constant over the whole range of measurements
1) Does the new tool agree with the Goldoldoldolden Standard?
(correlation analysis & Bland-Altman methodology)
2) Does it give the best information, which is not otherwise
available?
3) Does the clinician may alter his
a. decision making
b. therapy
because of it ?
4) Does the patient do better (outcome)?
A & B
Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1
1) Does the new tool agree with the Goldoldoldolden Standard?
(correlation analysis & Bland-Altman methodology)
2) Does it give the best information, which is not otherwise
available?
3) Does the clinician may alter his
a. decision making
b. therapy
because of it ?
4) Does the patient do better (outcome)?
1)
Intermittent gas analysis may provide only a snapshot
of blood gases fluctuations occurring even in
stable patients in the intensive care unit;
2)2)
The extra-arterial blood gas monitors are not continuous
and the rate of measurements is operator dependent;
Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1
venousvenousvenousvenous
saturatiosaturatiosaturatiosaturationcontinuouscontinuouscontinuouscontinuous
exhaustexhaustexhaustexhaust
capnographycapnographycapnographycapnography
Stinkens D, Himpe D, Thyssen P, De Bakker A, Smets W, Borms S, Suy M, Muylaert P,
Van Hove M, Theunissen W, Van Cauwelaert P. Perfusion 1996; 11(6):471-80.
1) Does the new tool agree with the Goldoldoldolden Standard?
(correlation analysis & Bland-Altman methodology)
2) Does it give the best information, which is not otherwise
available?
3) Does the clinician may alter his
a. decision making
b. therapy
because of it ?
4) Does the patient do better (outcome)?
1) Does the new tool agree with the Goldoldoldolden Standard?
(correlation analysis & Bland-Altman methodology)
2) Does it give the best information, which is not otherwise
available?
3) Does the clinician may alter his
a. decision making
b. therapy
because of it ?
4) Does the patient do better (outcome)?
Conclusion:
Our findings need to be confirmed by larger studies to prove its
reliability in the clinical setting. The intra-arterial blood gas
monitors present some drawbacks related to the intra-arterial monitors present some drawbacks related to the intra-arterial
environment and the indwelling sensor.
Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1Gelsomino et al. BMC Anesthesiology 2011, 11:1
Health Health Health Health EconomyEconomyEconomyEconomy
CostCostCostCost----EffectivenessEffectivenessEffectivenessEffectiveness Ratio Ratio Ratio Ratio ----> ICER> ICER> ICER> ICER
Incremental comparison costscosts & & outcomeoutcome effectseffects
of alternatives versus standard care:
Does the Does the Does the Does the Does the Does the Does the Does the patientpatientpatientpatientpatientpatientpatientpatient do do do do do do do do betterbetterbetterbetterbetterbetterbetterbetter and at and at and at and at and at and at and at and at whatwhatwhatwhatwhatwhatwhatwhat costcostcostcostcostcostcostcost ????????
Standard treatment or tool (comparator):
C1 & E1
New (alternative) tool:
C2 & E2
CE-ratio: cost per unit of effect -> C2 - C1
E2 - E1
DECISIO
NDECISIO
NDECISIO
NDECISIO
N
OutcomeOutcomeOutcomeOutcome PayPayPayPay----offoffoffoff
OutcomeOutcomeOutcomeOutcome
PPPProbabilityrobabilityrobabilityrobability
++++
----
New New New New ToolToolToolTool
AAAA
PPPProbabilityrobabilityrobabilityrobability
++++
----
BBBB
Old Old Old Old Tool as Tool as Tool as Tool as
ComparatorComparatorComparatorComparator
((((cheapercheapercheapercheaper ?)?)?)?)
AAAAAAAA
CCCCCCCCNewNewNewNewNewNewNewNew
ToolToolToolToolToolToolToolTool
Cost
AAAAAAAA
EffectivityEffectivityEffectivityEffectivity (outcome !)
.Linking payments to improved
performance by health care providers (P4P);
.This form of payment holds health care
providers accountable for both the
““““ValueValueValueValue BasedBasedBasedBased PurchasingPurchasingPurchasingPurchasing””””
providers accountable for both the
cost and quality of care they deliver (P4Q);
.It attempts to reduce inappropriate
care and to identify and reward the
best-performing providers;
“The Doctor “The Doctor “The Doctor “The Doctor fightsfightsfightsfights forforforfor hishishishis theorytheorytheorytheory, , , ,
the the the the PatientPatientPatientPatient forforforfor hishishishis live...”live...”live...”live...”Oscar Wilde (1854Oscar Wilde (1854--1900)1900)
POCT & GDTPOCT & GDTPOCT & GDTPOCT & GDT
Operating Theatre Operating Theatre Operating Theatre Operating Theatre
acid-base
strategy
during CPB
Patel R. L. et al.; J Patel R. L. et al.; J Patel R. L. et al.; J Patel R. L. et al.; J ThoracThoracThoracThorac CardiovascCardiovascCardiovascCardiovasc SurgSurgSurgSurg 1996;111:12671996;111:12671996;111:12671996;111:1267----1279127912791279
patients receiving alpha-stat managementhad less disruption of cerebral auto-regulation during cardiopulmonary bypass, accompanied by a reduced incidenceof postoperative cerebral dysfunction. bypass, accompanied by a reduced incidenceof postoperative cerebral dysfunction.
Cardiac-related mortality
Noncardiac-related mortality
8
10
12
14
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality & average blood glucoseMortality & average blood glucoseMortality & average blood glucoseMortality & average blood glucose
levels after cardiac surgerylevels after cardiac surgerylevels after cardiac surgerylevels after cardiac surgery
#2a.
FurnaryFurnaryFurnaryFurnary AP et al. J AP et al. J AP et al. J AP et al. J ThoracThoracThoracThorac CardiovascCardiovascCardiovascCardiovasc Surg. 2003Surg. 2003Surg. 2003Surg. 2003; 125: 1007; 125: 1007; 125: 1007; 125: 1007----1021102110211021....
0
2
4
6
8
<150 150–175 175–200 200–225 225–250 >250
Average Postoperative Glucose (mg/dL)
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
Mortality %
#2b.
Demers Demers Demers Demers et al., Ann of et al., Ann of et al., Ann of et al., Ann of ThoracThoracThoracThorac SurgSurgSurgSurg 2000200020002000; 70: 2082; 70: 2082; 70: 2082; 70: 2082----2086208620862086
< 10 %< 10 %< 10 %< 10 %
10101010----20 %20 %20 %20 %
Weight gain after cardiac surgery
Colloid Osmotic PressureColloid Osmotic PressureColloid Osmotic PressureColloid Osmotic Pressure
#3.
Lowell, CCM 1990 18: 728Lowell, CCM 1990 18: 728Lowell, CCM 1990 18: 728Lowell, CCM 1990 18: 728
10101010----20 %20 %20 %20 %
> 20 %> 20 %> 20 %> 20 %
0000 20202020 40404040 60606060 80808080 100100100100
Mortality %Mortality %Mortality %Mortality %
““““OneOneOneOne shouldshouldshouldshould neverneverneverneverorder order order order orororor prescribeprescribeprescribeprescribe a a a a transfusiontransfusiontransfusiontransfusion, , , ,
KarlKarlKarlKarl LandsteinerLandsteinerLandsteinerLandsteiner::::
((((BloodBloodBloodBlood----groupsgroupsgroupsgroups 1901 1901 1901 1901 ---- NobelNobelNobelNobel----PrizePrizePrizePrize 1930)1930)1930)1930)
#4.
transfusiontransfusiontransfusiontransfusion, , , , unlessunlessunlessunless itititit is is is is worthworthworthworth the the the the risksrisksrisksrisks...”...”...”...”
No transfusion
Engoren et al. Ann Thorac Surg 2002; 74:1 180Engoren et al. Ann Thorac Surg 2002; 74:1 180Engoren et al. Ann Thorac Surg 2002; 74:1 180Engoren et al. Ann Thorac Surg 2002; 74:1 180----6666
Transfusion
MurphyMurphyMurphyMurphy, G. J. et al. , G. J. et al. , G. J. et al. , G. J. et al. CirculationCirculationCirculationCirculation 2007; 116: 25442007; 116: 25442007; 116: 25442007; 116: 2544----2552255225522552
KashukKashukKashukKashuk et al. Transfusion 52:23, 2012et al. Transfusion 52:23, 2012et al. Transfusion 52:23, 2012et al. Transfusion 52:23, 2012
Weber et al. Anesthesiology 117:531, 2012Weber et al. Anesthesiology 117:531, 2012Weber et al. Anesthesiology 117:531, 2012Weber et al. Anesthesiology 117:531, 2012
Weber et al. Anesthesiology 117:531, 2012Weber et al. Anesthesiology 117:531, 2012Weber et al. Anesthesiology 117:531, 2012Weber et al. Anesthesiology 117:531, 2012
The different ‘faces’ of POCT:
- Glucometer-like
- Lab nextdoor
- Continuous measurement- Continuous measurement
ABG, BG, Htc ….
the ‘POCT lab’ the ‘POCT lab’ the ‘POCT lab’ the ‘POCT lab’ nextdoornextdoornextdoornextdoor …………
readily and continuously readily and continuously readily and continuously readily and continuously
available available available available ---- on demandon demandon demandon demand
rapid response rapid response rapid response rapid response
fast communication fast communication fast communication fast communication
minimal bureaucracyminimal bureaucracyminimal bureaucracyminimal bureaucracy
Clinical Chemistry & Biology Clinical Chemistry & Biology Clinical Chemistry & Biology Clinical Chemistry & Biology –––– Back to the Future:Back to the Future:Back to the Future:Back to the Future:
.maintenance & calibration POCT equipment
.QC
.management infrastructure
------------------------------------------------------------------------
.theoretical concepts and interpretation .theoretical concepts and interpretation
(targets and algorithms)
.purchasing process & assessment
of diagnostic technology (outcome related)