continuous monitoring: state of the art &&&& pointpoint ...€¦ · the right tool...

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 …

State of the art ?State of the art ?State of the art ?State of the art ?

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

A case (on special request): Terumo CDI 500

continuous intra arterial ABG analyser




available?


a. decision making

b. therapy

because of it ?


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




available?


a. decision making

b. therapy

because of it ?


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;


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.




available?


a. decision making

b. therapy

because of it ?


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.


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)

better outcomes

by

Goal Directed Therapy

by

hitting the right target(s)

using reliable information

POCT & GDTPOCT & GDTPOCT & GDTPOCT & GDT

Operating Theatre Operating Theatre Operating Theatre Operating Theatre

Acid-base Management

during

Hypothermic

#1.

Hypothermic

Cardio-Pulmonary-Bypass

p. 471

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

dynamic

visco-elastic

coagulation

TEG

coagulation

testing

Sonoclot

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

Massive Hemorrhage: “lethal triad”

The different ‘faces’ of POCT:

- Glucometer-like

- Lab nextdoor

- Continuous measurement- Continuous measurement

ABG, BG, Htc ….

1991

OR

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)

“The difficulty lies not in new ideas,

but in escaping the old ones…”

John Maynard Keynes

Questions ?

continuous monitoring: state of the art &&&& pointpoint ...€¦ · the right tool...

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