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Gairola S, Solanki SL, Patkar S, Goel M. Artificial Intelligence in Perioperative Planning and Management of Liver Resection. Indian J Surg Oncol 2024; 15:186-195. [PMID: 38818006 PMCID: PMC11133260 DOI: 10.1007/s13193-024-01883-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/16/2024] [Indexed: 06/01/2024] Open
Abstract
Artificial intelligence (AI) is a speciality within computer science that deals with creating systems that can replicate the intelligence of a human mind and has problem-solving abilities. AI includes a diverse array of techniques and approaches such as machine learning, neural networks, natural language processing, robotics, and expert systems. An electronic literature search was conducted using the databases of "PubMed" and "Google Scholar". The period for the search was from 2000 to June 2023. The search terms included "artificial intelligence", "machine learning", "liver cancers", "liver tumors", "hepatectomy", "perioperative" and their synonyms in various combinations. The search also included all MeSH terms. The extracted articles were further reviewed in a step-wise manner for identification of relevant studies. A total of 148 articles were identified after the initial literature search. Initial review included screening of article titles for relevance and identifying duplicates. Finally, 65 articles were reviewed for this review article. The future of AI in liver cancer planning and management holds immense promise. AI-driven advancements will increasingly enable precise tumour detection, location, and characterisation through enhanced image analysis. ML algorithms will predict patient-specific treatment responses and complications, allowing for tailored therapies. Surgical robots and AI-guided procedures will enhance the precision of liver resections, reducing risks and improving outcomes. AI will also streamline patient monitoring, better hemodynamic management, enabling early detection of recurrence or complications. Moreover, AI will facilitate data-driven research, accelerating the development of novel treatments and therapies. Ultimately, AI's integration will revolutionise liver cancer care, offering personalised, efficient and effective solutions, improving patients' quality of life and survival rates.
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Affiliation(s)
- Shruti Gairola
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Sohan Lal Solanki
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Shraddha Patkar
- Division of Hepatobiliary Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Mahesh Goel
- Division of Hepatobiliary Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
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Coeckelenbergh S, Vincent JL, Duranteau J, Joosten A, Rinehart J. Perioperative Fluid and Vasopressor Therapy in 2050: From Experimental Medicine to Personalization Through Automation. Anesth Analg 2024; 138:284-294. [PMID: 38215708 DOI: 10.1213/ane.0000000000006672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Intravenous (IV) fluids and vasopressor agents are key components of hemodynamic management. Since their introduction, their use in the perioperative setting has continued to evolve, and we are now on the brink of automated administration. IV fluid therapy was first described in Scotland during the 1832 cholera epidemic, when pioneers in medicine saved critically ill patients dying from hypovolemic shock. However, widespread use of IV fluids only began in the 20th century. Epinephrine was discovered and purified in the United States at the end of the 19th century, but its short half-life limited its implementation into patient care. Advances in venous access, including the introduction of the central venous catheter, and the ability to administer continuous infusions of fluids and vasopressors rather than just boluses, facilitated the use of fluids and adrenergic agents. With the advent of advanced hemodynamic monitoring, most notably the pulmonary artery catheter, the role of fluids and vasopressors in the maintenance of tissue oxygenation through adequate cardiac output and perfusion pressure became more clearly established, and hemodynamic goals could be established to better titrate fluid and vasopressor therapy. Less invasive hemodynamic monitoring techniques, using echography, pulse contour analysis, and heart-lung interactions, have facilitated hemodynamic monitoring at the bedside. Most recently, advances have been made in closed-loop fluid and vasopressor therapy, which apply computer assistance to interpret hemodynamic variables and therapy. Development and increased use of artificial intelligence will likely represent a major step toward fully automated hemodynamic management in the perioperative environment in the near future. In this narrative review, we discuss the key events in experimental medicine that have led to the current status of fluid and vasopressor therapies and describe the potential benefits that future automation has to offer.
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Affiliation(s)
- Sean Coeckelenbergh
- From the Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Paris, France
- Outcomes Research Consortium, Cleveland, Ohio
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Duranteau
- From the Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Paris, France
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital De Bicêtre, Paris, France
| | - Alexandre Joosten
- From the Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Paris, France
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital De Bicêtre, Paris, France
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, Ohio
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, California
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Rinehart J, Coeckelenbergh S, Srivastava I, Cannesson M, Joosten A. Physiological Modeling of Hemodynamic Responses to Sodium Nitroprusside. J Pers Med 2023; 13:1101. [PMID: 37511714 PMCID: PMC10381667 DOI: 10.3390/jpm13071101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Computational modeling of physiology has become a routine element in the development, evaluation, and safety testing of many types of medical devices. Members of the Food and Drug Administration have recently published a manuscript detailing the development, validation, and sensitivity testing of a computational model for blood volume, cardiac stroke volume, and blood pressure, noting that such a model might be useful in the development of closed-loop fluid administration systems. In the present study, we have expanded on this model to include the pharmacologic effect of sodium nitroprusside and calibrated the model against our previous experimental animal model data. METHODS Beginning with the model elements in the original publication, we added six new parameters to control the effect of sodium nitroprusside: two for the onset time and clearance rates, two for the stroke volume effect (which includes venodilation as a "hidden" element), and two for the direct effect on arterial blood pressure. Using this new model, we then calibrated the predictive performance against previously collected animal study data using nitroprusside infusions to simulate shock with the primary emphasis on MAP. Root-mean-squared error (RMSE) was calculated, and the performance was compared to the performance of the model in the original study. RESULTS RMSE of model-predicted MAP to actual MAP was lower than that reported in the original model, but higher for SV and CO. The individually fit models showed lower RMSE than using the population average values for parameters, suggesting the fitting process was effective in identifying improved parameters. Use of partially fit models after removal of the lowest variance population parameters showed a very minor decrement in improvement over the fully fit models. CONCLUSION The new model added the clinical effects of SNP and was successfully calibrated against experimental data with an RMSE of <10% for mean arterial pressure. Model-predicted MAP showed an error similar to that seen in the original base model when using fluid shifts, heart rate, and drug dose as model inputs.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868, USA
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Sean Coeckelenbergh
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, 1050 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Hôpitaux Universitaires Paris-Sud, Université Paris-Saclay, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, 44195 Paris, France
| | - Ishita Srivastava
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868, USA
| | - Maxime Cannesson
- Departments of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, 1050 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Hôpitaux Universitaires Paris-Sud, Université Paris-Saclay, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, 44195 Paris, France
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Polz M, Bergmoser K, Horn M, Schörghuber M, Lozanović J, Rienmüller T, Baumgartner C. A system theory based digital model for predicting the cumulative fluid balance course in intensive care patients. Front Physiol 2023; 14:1101966. [PMID: 37123264 PMCID: PMC10133509 DOI: 10.3389/fphys.2023.1101966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Abstract
Background: Surgical interventions can cause severe fluid imbalances in patients undergoing cardiac surgery, affecting length of hospital stay and survival. Therefore, appropriate management of daily fluid goals is a key element of postoperative intensive care in these patients. Because fluid balance is influenced by a complex interplay of patient-, surgery- and intensive care unit (ICU)-specific factors, fluid prediction is difficult and often inaccurate. Methods: A novel system theory based digital model for cumulative fluid balance (CFB) prediction is presented using recorded patient fluid data as the sole parameter source by applying the concept of a transfer function. Using a retrospective dataset of n = 618 cardiac intensive care patients, patient-individual models were created and evaluated. RMSE analyses and error calculations were performed for reasonable combinations of model estimation periods and clinically relevant prediction horizons for CFB. Results: Our models have shown that a clinically relevant time horizon for CFB prediction with the combination of 48 h estimation time and 8-16 h prediction time achieves high accuracy. With an 8-h prediction time, nearly 50% of CFB predictions are within ±0.5 L, and 77% are still within the clinically acceptable range of ±1.0 L. Conclusion: Our study has provided a promising proof of principle and may form the basis for further efforts in the development of computational models for fluid prediction that do not require large datasets for training and validation, as is the case with machine learning or AI-based models. The adaptive transfer function approach allows estimation of CFB course on a dynamically changing patient fluid balance system by simulating the response to the current fluid management regime, providing a useful digital tool for clinicians in daily intensive care.
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Affiliation(s)
- Mathias Polz
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Katharina Bergmoser
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
- CBmed Center for Biomarker Research in Medicine, Graz, STM, Austria
| | - Martin Horn
- Institute of Automation and Control, Graz University of Technology, Graz, STM, Austria
| | - Michael Schörghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, STM, Austria
| | - Jasmina Lozanović
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Theresa Rienmüller
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Christian Baumgartner
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
- *Correspondence: Christian Baumgartner,
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Gricourt Y, Prin Derre C, Demattei C, Bertran S, Louart B, Muller L, Simon N, Lefrant JY, Cuvillon P, Jaber S, Roger C. A Pilot Study Assessing a Closed-Loop System for Goal-Directed Fluid Therapy in Abdominal Surgery Patients. J Pers Med 2022; 12:jpm12091409. [PMID: 36143194 PMCID: PMC9505637 DOI: 10.3390/jpm12091409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This prospective multicentre pilot study of patients scheduled for elective major abdominal surgery aimed to validate the fluid challenge (FC) proposed by the closed-loop (CL) system via anaesthesiologist assessment. Methods: This was a phase II trial consisting of two inclusion stages (SIMON method). Each FC (250 mL saline solution for 10 min) proposed by the CL was systematically validated by the anaesthesiologist who could either confirm or refuse the FC or give FC without the CL system. A ≥ 95% agreement between the CL and the anaesthesiologist was considered acceptable. Results: The study was interrupted after interim analysis of the first 19 patients (10 men, median age = 61 years, median body mass index = 26 kg/m2). The anaesthesiologists accepted 165/205 (80%) of fluid boluses proposed by the CL. Median cardiac index (CI) was 2.9 (interquartile: IQ (2.7; 3.4) L/min/m2) and the median coefficient of variation (CV) for CI was 13% (10; 17). Fifteen out of nineteen patients (79%) had a mean CI > 2.5 L/min/m2 or spent > 85% surgery time with pulse pressure variation < 13%. No adverse events related to the CL were reported. Conclusion: In this study of patients scheduled for elective major abdominal surgery, the agreement between CL and anaesthesiologist for giving fluid challenge was 80%, suggesting that CL cannot replace the physician but could help in decision making.
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Affiliation(s)
- Yann Gricourt
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Camille Prin Derre
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Christophe Demattei
- Laboratoire de Biostatistique, Epidémiologie Clinique, Santé Publique Innovation et Méthodologie (BESPIM), Pôle Pharmacie, Santé Publique, Nîmes University Hospital, 30900 Nîmes, France
| | - Sébastien Bertran
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
- Polyclinique Grand Sud, 350 Avenue Saint-André de Codols, 30000 Nîmes, France
| | - Benjamin Louart
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Laurent Muller
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Natacha Simon
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Jean-Yves Lefrant
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
- Correspondence: ; Tel.: +33-4-66-68-30-50; Fax: +33-4-66-68-38-41
| | - Philippe Cuvillon
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Samir Jaber
- Département d’Anesthésie Réanimation B St Eloi Hospital, 80 Avenue Augustin Fliche, 34295 Montpellier, France
| | - Claire Roger
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
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Closed-Loop Controlled Fluid Administration Systems: A Comprehensive Scoping Review. J Pers Med 2022; 12:jpm12071168. [PMID: 35887665 PMCID: PMC9315597 DOI: 10.3390/jpm12071168] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
Physiological Closed-Loop Controlled systems continue to take a growing part in clinical practice, offering possibilities of providing more accurate, goal-directed care while reducing clinicians’ cognitive and task load. These systems also provide a standardized approach for the clinical management of the patient, leading to a reduction in care variability across multiple dimensions. For fluid management and administration, the advantages of closed-loop technology are clear, especially in conditions that require precise care to improve outcomes, such as peri-operative care, trauma, and acute burn care. Controller design varies from simplistic to complex designs, based on detailed physiological models and adaptive properties that account for inter-patient and intra-patient variability; their maturity level ranges from theoretical models tested in silico to commercially available, FDA-approved products. This comprehensive scoping review was conducted in order to assess the current technological landscape of this field, describe the systems currently available or under development, and suggest further advancements that may unfold in the coming years. Ten distinct systems were identified and discussed.
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Gholami B, Haddad WM, Bailey JM, Muir WW. Closed-Loop Control for Fluid Resuscitation: Recent Advances and Future Challenges. Front Vet Sci 2021; 8:642440. [PMID: 33708814 PMCID: PMC7940185 DOI: 10.3389/fvets.2021.642440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/02/2021] [Indexed: 11/13/2022] Open
Abstract
Fluid therapy is extensively used to treat traumatized patients as well as patients during surgery. The fluid therapy process is complex due to interpatient variability in response to therapy as well as other complicating factors such as comorbidities and general anesthesia. These complexities can result in under- or over-resuscitation. Given the complexity of the fluid management process as well as the increased capabilities in hemodynamic monitoring, closed-loop fluid management can reduce the workload of the overworked clinician while ensuring specific constraints on hemodynamic endpoints are met with higher accuracy. The goal of this paper is to provide an overview of closed-loop control systems for fluid management and highlight several key steps in transitioning such a technology from bench to the bedside.
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Affiliation(s)
| | - Wassim M Haddad
- School of Aerospace Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - James M Bailey
- Northeast Georgia Medical Center, Gainesville, GA, United States
| | - William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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Joosten A, Rinehart J, Bardaji A, Van der Linden P, Jame V, Van Obbergh L, Alexander B, Cannesson M, Vacas S, Liu N, Slama H, Barvais L. Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery: A Randomized Controlled Trial. Anesthesiology 2020; 132:253-266. [PMID: 31939839 PMCID: PMC7517610 DOI: 10.1097/aln.0000000000003014] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cognitive changes after anesthesia and surgery represent a significant public health concern. We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia. METHODS In this single-center, patient-and-evaluator-blinded, two-arm, parallel, randomized controlled, superiority study, 90 patients having noncardiac surgery under general anesthesia were randomly assigned to one of two groups. In the control group, anesthesia management was performed manually while in the closed-loop group, the titration of anesthesia, analgesia, fluids, and ventilation was performed by three independent controllers. The primary outcome was a change in a cognition score (the 30-item Montreal Cognitive Assessment) from preoperative values to those measures 1 week postsurgery. Secondary outcomes included a battery of neurocognitive tests completed at both 1 week and 3 months postsurgery as well as 30-day postsurgical outcomes. RESULTS Forty-three controls and 44 closed-loop patients were assessed for the primary outcome. There was a difference in the cognition score compared to baseline in the control group versus the closed-loop group 1 week postsurgery (-1 [-2 to 0] vs. 0 [-1 to 1]; difference 1 [95% CI, 0 to 3], P = 0.033). Patients in the closed-loop group spent less time during surgery with a Bispectral Index less than 40, had less end-tidal hypocapnia, and had a lower fluid balance compared to the control group. CONCLUSIONS Automated anesthetic management using the combination of three controllers outperforms manual control and may have an impact on delayed neurocognitive recovery. However, given the study design, it is not possible to determine the relative contribution of each controller on the cognition score.
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Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology (A.J., A.B., V.J., L.V.O, L.B.) Department of Clinical and Cognitive Neuropsychology (H.S.) Erasme Hospital, and Department of Anesthesiology, Brugmann Hospital (P.V.d.L.), Université Libre de Bruxelles, Brussels, Belgium Department of Anesthesiology and Intensive Care, University of Paris-Saclay, Bicetre Hospital, Le Kremlin-Bicêtre, Paris, France (A.J.) Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California (J.R.) Department of Anesthesiology, University of California, San Diego, San Diego, California (B.A.) Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California (M.C., S.V.) Department of Anesthesiology, Foch Hospital, Suresnes, Paris, France (N.L.) Outcome Research Consortium, Cleveland Clinic, Cleveland, Ohio (N.L.)
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Joosten A, Raj Lawrence S, Colesnicenco A, Coeckelenbergh S, Vincent JL, Van der Linden P, Cannesson M, Rinehart J. Personalized Versus Protocolized Fluid Management Using Noninvasive Hemodynamic Monitoring (Clearsight System) in Patients Undergoing Moderate-Risk Abdominal Surgery. Anesth Analg 2020; 129:e8-e12. [PMID: 29878939 DOI: 10.1213/ane.0000000000003553] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Advances in noninvasive hemodynamic monitoring systems allow delivery of goal-directed fluid therapy and could therefore be used in less-invasive surgical procedures. In this randomized controlled trial, we compared closed-loop-assisted goal-directed fluid therapy using a noninvasive cardiac output (Clearsight system) monitor (personalized approach) to a protocolized fluid therapy approach in 40 patients undergoing moderate-risk laparoscopic abdominal surgery. Cardiac output and stroke volume variations were not significantly different in both groups and remained within predefined target values >90% of the study time. Personalized fluid therapy does not seem to offer any hemodynamic advantage over a protocolized approach in this population.
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Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Shalini Raj Lawrence
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandra Colesnicenco
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Sean Coeckelenbergh
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Louis Vincent
- Department of Intensive Care, CUB Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anesthesiology, Centre Hospitalo-Universitaire (CHU) Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
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Automated systems for perioperative goal-directed hemodynamic therapy. J Anesth 2019; 34:104-114. [DOI: 10.1007/s00540-019-02683-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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Joosten A, Alexander B, Duranteau J, Taccone FS, Creteur J, Vincent JL, Cannesson M, Rinehart J. Feasibility of closed-loop titration of norepinephrine infusion in patients undergoing moderate- and high-risk surgery. Br J Anaesth 2019; 123:430-438. [PMID: 31255290 DOI: 10.1016/j.bja.2019.04.064] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/09/2019] [Accepted: 05/08/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Vasopressor agents are used to prevent intraoperative hypotension and ensure adequate perfusion. Vasopressors are usually administered as intermittent boluses or manually adjusted infusions, but this practice requires considerable time and attention. We have developed a closed-loop vasopressor (CLV) controller to correct hypotension more efficiently. Here, we conducted a proof-of-concept study to assess the feasibility and performance of CLV control in surgical patients. METHODS Twenty patients scheduled for elective surgical procedures were included in this study. The goal of the CLV system was to maintain MAP within 5 mm Hg of the target MAP by automatically adjusting the rate of a norepinephrine infusion using MAP values recorded continuously from an arterial catheter. The primary outcome was the percentage of time that patients were hypotensive, as defined by a MAP of 5 mm Hg below the chosen target. Secondary outcomes included the total dose of norepinephrine, percentage of time with hypertension (MAP>5 mm Hg of the chosen target), raw percentage "time in target" and Varvel performance criteria. RESULTS The 20 subjects (median age: 64 years [52-71]; male (35%)) underwent elective surgery lasting 154 min [124-233]. CLV control maintained MAP within ±5 mm Hg of the target for 91.6% (85.6-93.3) of the intraoperative period. Subjects were hypotensive for 2.6% of the intraoperative period (range, 0-8.4%). Additional performance criteria for the controller included mean absolute performance error of 2.9 (0.8) and mean predictive error of 0.5 (1.0). No subjects experienced major complications. CONCLUSIONS In this proof of concept study, CLV control minimised perioperative hypotension in subjects undergoing moderate- or high-risk surgery. Further studies to demonstrate efficacy are warranted. TRIAL REGISTRY NUMBER NCT03515161 (ClinicalTrials.gov).
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
| | - Brenton Alexander
- Department of Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California-Irvine, Irvine, CA, USA
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12
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Joosten A, Jame V, Alexander B, Chazot T, Liu N, Cannesson M, Rinehart J, Barvais L. Feasibility of Fully Automated Hypnosis, Analgesia, and Fluid Management Using 2 Independent Closed-Loop Systems During Major Vascular Surgery: A Pilot Study. Anesth Analg 2019; 128:e88-e92. [PMID: 31094779 DOI: 10.1213/ane.0000000000003433] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Automated titration of intravenous anesthesia and analgesia using processed electroencephalography monitoring is no longer a novel concept. Closed-loop control of fluid administration to provide goal-directed fluid therapy has also been increasingly described. However, simultaneously combining 2 independent closed-loop systems together in patients undergoing major vascular surgery has not been previously detailed. The aim of this pilot study was to evaluate the clinical performance of fully automated hypnosis, analgesia, and fluid management using 2 independent closed-loop controllers in patients undergoing major vascular surgery before implementation within a larger study evaluating true patient outcomes.
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Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Vincent Jame
- Department of Anesthesiology, Centre hospitalo-Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Thierry Chazot
- Department of Anesthesiology, Hopital Foch, Suresnes, France
| | - Ngai Liu
- Department of Anesthesiology, Hopital Foch, Suresnes, France
- Outcomes Research Consortium, Cleveland, Ohio
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Luc Barvais
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Implementation of closed-loop-assisted intra-operative goal-directed fluid therapy during major abdominal surgery: A case-control study with propensity matching. Eur J Anaesthesiol 2019; 35:650-658. [PMID: 29750699 DOI: 10.1097/eja.0000000000000827] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Goal-directed fluid therapy (GDFT) has been associated with improved patient outcomes. However, implementation of GDFT protocols remains low despite growing published evidence and the recommendations of multiple regulatory bodies in Europe. We developed a closed-loop-assisted GDFT management system linked to a pulse contour monitor to assist anaesthesiologists in applying GDFT. OBJECTIVE To assess the impact of our closed-loop system in patients undergoing major abdominal surgery in an academic hospital without a GDFT programme. DESIGN A case-control study with propensity matching. SETTING Operating rooms, Erasme Hospital, Brussels. PATIENTS All patients who underwent elective open major abdominal surgery between January 2013 and December 2016. INTERVENTION Implementation of our closed-loop-assisted GDFT in April 2015. METHODS A total of 104 patients managed with closed-loop-assisted GDFT were paired with a historical cohort of 104 consecutive non-GDFT patients. The historical control group consisted of patients treated before the implementation of the closed-loop-system, and who did not receive GDFT. In the closed-loop group, the system delivered a baseline crystalloid infusion of 3 ml kg h and additional 100 ml fluid boluses of either a crystalloid or colloid for haemodynamic optimisation. MAIN OUTCOME MEASURES The primary outcome was intra-operative net fluid balance. Secondary outcomes were composite major postoperative complications, composite minor postoperative complications and hospital length of stay (LOS). RESULTS Baseline characteristics were similar in both groups. Patients in the closed-loop group had a lower net intra-operative fluid balance compared with the historical group (median interquartile range [IQR] 2.9 [1.6 to 4.4] vs. 6.2 [4.0 to 8.3] ml kg h; P < 0.001). Incidences of major and minor postoperative complications were lower (17 vs. 32%, P = 0.015 and 31 vs. 45%, P = 0.032, respectively) and hospital LOS shorter [median (IQR) 10 (6 to 15) vs. 12 (9 to 18) days, P = 0.022] in the closed-loop group. CONCLUSION Implementation of our closed-loop-assisted GDFT strategy resulted in a reduction in intra-operative net fluid balance, which was associated with reduced postoperative complications and shorter hospital LOS. TRIAL REGISTRATION NUMBER NCT02978430.
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14
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Closed-loop hemodynamic management. Best Pract Res Clin Anaesthesiol 2019; 33:199-209. [PMID: 31582099 DOI: 10.1016/j.bpa.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
As the operating room and intensive care settings become increasingly complex, the required vigilance practitioners must dedicate to a wide array of clinical systems has increased concordantly. The resulting shortage of available attention to these various clinical tasks creates a vacuum for the introduction of systems that can administer well-established goal-directed therapies without significant provider feedback. Recently, there has been an explosion of academic exploration into creating such automated systems, with a strong specific focus on hemodynamic control. Within this field, the largest focus has been on goal-directed fluid therapy as systems automating vasopressor administration have only recently become viable options. Our goal in this review article is to summarize the validity of the relevant goal-directed hemodynamic systems and explore the expanding role of automation within these systems.
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15
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Parvinian B, Pathmanathan P, Daluwatte C, Yaghouby F, Gray RA, Weininger S, Morrison TM, Scully CG. Credibility Evidence for Computational Patient Models Used in the Development of Physiological Closed-Loop Controlled Devices for Critical Care Medicine. Front Physiol 2019; 10:220. [PMID: 30971934 PMCID: PMC6445134 DOI: 10.3389/fphys.2019.00220] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/20/2019] [Indexed: 12/16/2022] Open
Abstract
Physiological closed-loop controlled medical devices automatically adjust therapy delivered to a patient to adjust a measured physiological variable. In critical care scenarios, these types of devices could automate, for example, fluid resuscitation, drug delivery, mechanical ventilation, and/or anesthesia and sedation. Evidence from simulations using computational models of physiological systems can play a crucial role in the development of physiological closed-loop controlled devices; but the utility of this evidence will depend on the credibility of the computational model used. Computational models of physiological systems can be complex with numerous non-linearities, time-varying properties, and unknown parameters, which leads to challenges in model assessment. Given the wide range of potential uses of computational patient models in the design and evaluation of physiological closed-loop controlled systems, and the varying risks associated with the diverse uses, the specific model as well as the necessary evidence to make a model credible for a use case may vary. In this review, we examine the various uses of computational patient models in the design and evaluation of critical care physiological closed-loop controlled systems (e.g., hemodynamic stability, mechanical ventilation, anesthetic delivery) as well as the types of evidence (e.g., verification, validation, and uncertainty quantification activities) presented to support the model for that use. We then examine and discuss how a credibility assessment framework (American Society of Mechanical Engineers Verification and Validation Subcommittee, V&V 40 Verification and Validation in Computational Modeling of Medical Devices) for medical devices can be applied to computational patient models used to test physiological closed-loop controlled systems.
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Affiliation(s)
- Bahram Parvinian
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, MD, United States
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16
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Scully CG, Pathmanathan P, Daluwatte C, Yaghouby F, Gray RA, Weininger S, Morrison TM, Parvinian B. Applying a Computational Model Credibility Framework to Physiological Closed-loop Controlled Medical Device Testing. IEEE LIFE SCIENCES CONFERENCE. LIFE SCIENCES CONFERENCE 2018; 2018:130-133. [PMID: 34514471 PMCID: PMC8432287 DOI: 10.1109/lsc.2018.8572270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Physiological closed-loop controlled medical devices are safety-critical systems that combine patient monitors with therapy delivery devices to automatically titrate therapy to meet a patient's current need. Computational models of physiological systems can be used to test these devices and generate pre-clinical evidence of safety and performance before using the devices on patients. The credibility, utility, and acceptability of such model-based test results will depend on, among other factors, the computational model used. We examine how a recently developed risk-informed framework for establishing the credibility of computational models in medical device applications can be applied in the evaluation of physiological closed-loop controlled devices.
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Affiliation(s)
- Christopher G Scully
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Pras Pathmanathan
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Chathuri Daluwatte
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Farid Yaghouby
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Richard A Gray
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Sandy Weininger
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Tina M Morrison
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Bahram Parvinian
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
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17
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Gholami B, Haddad WM, Bailey JM, Geist B, Ueyama Y, Muir WW. A pilot study evaluating adaptive closed-loop fluid resuscitation during states of absolute and relative hypovolemia in dogs. J Vet Emerg Crit Care (San Antonio) 2018; 28:436-446. [PMID: 30117659 DOI: 10.1111/vec.12753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 04/02/2018] [Accepted: 05/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate and determine the performance of a partially automated as well as a fully automated closed-loop fluid resuscitation system during states of absolute and relative hypovolemia. DESIGN Prospective experimental trial. SETTING Research laboratory. ANIMALS Five adult Beagle dogs. METHODS Isoflurane anesthetized mechanically ventilated dogs were subjected to absolute hypovolemia (controlled: 2 trials; uncontrolled: 3 trials), relative hypovolemia (2 trials), and the combination of relative and absolute controlled hypovolemia (2 trials). Controlled and uncontrolled hypovolemia were produced by withdrawing blood from the carotid or femoral artery. Relative hypovolemia was produced by increasing the isoflurane concentration (1 trial) or by infusion of intravenous sodium nitroprusside (1 trial). Relative hypovolemia combined with controlled absolute hypovolemia was produced by increasing the isoflurane concentration (1 trial) and infusion of IV sodium nitroprusside (1 trial). Hemodynamic parameters including stroke volume variation (SVV) were continuously monitored and recorded in all dogs. A proprietary closed-loop fluid administration system based on fluid distribution and compartmental dynamical systems administered a continuous infusion of lactated Ringers solution in order to restore and maintain SVV to a predetermined target value. MEASUREMENTS AND MAIN RESULTS A total of 9 experiments were performed on 5 dogs. Hemodynamic parameters deteriorated and SVV increased during controlled or uncontrolled hypovolemia, relative hypovolemia, and during relative hypovolemia combined with controlled hypovolemia. Stroke volume variation was restored to baseline values during closed-loop fluid infusion. CONCLUSIONS Closed-loop fluid administration based on IV fluid distribution and compartmental dynamical systems can be used to provide goal directed fluid therapy during absolute or relative hypovolemia in mechanically ventilated isoflurane anesthetized dogs.
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Affiliation(s)
| | - Wassim M Haddad
- School of Aerospace Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - James M Bailey
- The Northeast Georgia Medical Center, Gainsville, GA, USA
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18
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Joosten A, Hafiane R, Pustetto M, Van Obbergh L, Quackels T, Buggenhout A, Vincent JL, Ickx B, Rinehart J. Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery. J Clin Monit Comput 2018; 33:15-24. [PMID: 29779129 DOI: 10.1007/s10877-018-0156-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/15/2018] [Indexed: 12/19/2022]
Abstract
The purpose of this study was to assess the effects of using a real time clinical decision-support system, "Assisted Fluid Management" (AFM), to guide goal-directed fluid therapy (GDFT) during major abdominal surgery. We compared a group of patients managed using the AFM system with a historical cohort of patients (control group) who had been managed using a manual GDFT strategy. Adherence to the protocol was defined as the relative intraoperative time spent with a stroke volume variation (SVV) < 13%. We hypothesised that patients in the AFM group would have more time during surgery with a SVV < 13% compared to the control group. All patients had a radial arterial line connected to a pulse contour analysis monitor and received a 2 ml/kg/h maintenance crystalloid infusion. Additional 250 ml crystalloid boluses were administered whenever measured SVV ≥ 13% in the control group, and when the software suggested a fluid bolus in the AFM group. We compared 46 AFM-guided patients to 38 controls. Patients in the AFM group spent significantly more time during surgery with a SVV < 13% compared to the control group (median 92% [82, 96] vs. 76% [54, 86]; P < 0.0005), and received less fluid overall (1775 ml [1225, 2425] vs. 2350 ml [1825, 3250]; P = 0.010). The incidence of postoperative complications was comparable in the two groups. Implementation of a decision support system for GDFT guidance resulted in a significantly longer period during surgery with a SVV < 13% with a reduced total amount of fluid administered. Trial registration: Clinical Trials.gov (NCT03141411).
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, CUB Erasme, Hopital ERASME, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium.
| | - Reda Hafiane
- Department of Anesthesiology, CUB Erasme, Hopital ERASME, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Marco Pustetto
- Department of Anesthesiology, CUB Erasme, Hopital ERASME, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, CUB Erasme, Hopital ERASME, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Thierry Quackels
- Department of Urology, CUB Erasme, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Alexis Buggenhout
- Department of Colorectal Surgery, CUB Erasme, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, CUB Erasme, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Brigitte Ickx
- Department of Anesthesiology, CUB Erasme, Hopital ERASME, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 the City Drive South, Orange, CA, USA
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Klingert W, Peter J, Thiel C, Thiel K, Rosenstiel W, Klingert K, Grasshoff C, Königsrainer A, Schenk M. Fully automated life support: an implementation and feasibility pilot study in healthy pigs. Intensive Care Med Exp 2018; 6:2. [PMID: 29340799 PMCID: PMC5770352 DOI: 10.1186/s40635-018-0168-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/09/2018] [Indexed: 01/31/2023] Open
Abstract
Background Automated systems are available in various application areas all over the world for the purpose of reducing workload and increasing safety. However, such support systems that would aid caregivers are still lacking in the medical sector. With respect to workload and safety, especially, the intensive care unit appears to be an important and challenging application field. Whereas many closed-loop subsystems for single applications already exist, no comprehensive system covering multiple therapeutic aspects and interactions is available yet. This paper describes a fully closed-loop intensive care therapy and presents a feasibility analysis performed in three healthy pigs over a period of 72 h each to demonstrate the technical and practical implementation of automated intensive care therapy. Methods The study was performed in three healthy, female German Landrace pigs under general anesthesia with endotracheal intubation. An arterial and a central venous line were implemented, and a suprapubic urinary catheter was inserted. Electrolytes, glucose levels, acid-base balance, and respiratory management were completely controlled by an automated fuzzy logic system based on individual targets. Fluid management by adaption of the respective infusion rates for the individual parameters was included. Results During the study, no manual modification of the device settings was allowed or required. Homoeostasis in all animals was kept stable during the entire observation period. All remote-controlled parameters were maintained within physiological ranges for most of the time (free arterial calcium 73%, glucose 98%, arterial base excess 89%, and etCO2 98%). Subsystem interaction was analyzed. Conclusions In the presented study, we demonstrate the feasibility of a fully closed-loop system, for which we collected high-resolution data on the interaction and response of the different subsystems. Further studies should use big data approaches to analyze and investigate the interactions between the subsystems in more detail.
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Affiliation(s)
- Wilfried Klingert
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.
| | - Jörg Peter
- Department of Computer Engineering, Tübingen University, Sand 13, 72076, Tübingen, Germany
| | - Christian Thiel
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Karolin Thiel
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Wolfgang Rosenstiel
- Department of Computer Engineering, Tübingen University, Sand 13, 72076, Tübingen, Germany
| | - Kathrin Klingert
- Department of Anesthesiology, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Christian Grasshoff
- Department of Anesthesiology, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Martin Schenk
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
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20
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Joosten A, Delaporte A, Ickx B, Touihri K, Stany I, Barvais L, Van Obbergh L, Loi P, Rinehart J, Cannesson M, Van der Linden P. Crystalloid versus Colloid for Intraoperative Goal-directed Fluid Therapy Using a Closed-loop System: A Randomized, Double-blinded, Controlled Trial in Major Abdominal Surgery. Anesthesiology 2017; 128:55-66. [PMID: 29068831 DOI: 10.1097/aln.0000000000001936] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The type of fluid and volume regimen given intraoperatively both can impact patient outcome after major surgery. This two-arm, parallel, randomized controlled, double-blind, bi-center superiority study tested the hypothesis that when using closed-loop assisted goal-directed fluid therapy, balanced colloids are associated with fewer postoperative complications compared to balanced crystalloids in patients having major elective abdominal surgery. METHODS One hundred and sixty patients were enrolled in the protocol. All patients had maintenance-balanced crystalloid administration of 3 ml · kg · h. A closed-loop system delivered additional 100-ml fluid boluses (patients were randomized to receive either a balanced-crystalloid or colloid solution) according to a predefined goal-directed strategy, using a stroke volume and stroke volume variation monitor. All patients were included in the analysis. The primary outcome was the Post-Operative Morbidity Survey score, a nine-domain scale, at day 2 postsurgery. Secondary outcomes included all postoperative complications. RESULTS Patients randomized in the colloid group had a lower Post-Operative Morbidity Survey score (median [interquartile range] of 2 [1 to 3] vs. 3 [1 to 4], difference -1 [95% CI, -1 to 0]; P < 0.001) and a lower incidence of postoperative complications. Total volume of fluid administered intraoperatively and net fluid balance were significantly lower in the colloid group. CONCLUSIONS Under our study conditions, a colloid-based goal-directed fluid therapy was associated with fewer postoperative complications than a crystalloid one. This beneficial effect may be related to a lower intraoperative fluid balance when a balanced colloid was used. However, given the study design, the mechanism for the difference cannot be determined with certainty.
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Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (A.J., B.I., K.T., L.B., L.V.O.); Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium (A.D., I.S., P.V.d.L.); Department of Abdominal Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (P.L.); Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California (J.R.); and Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California (M.C.)
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21
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Wagar MK, Magnuson J, Liu PT, Kirchner V, Wilhelm JJ, Freeman ML, Bellin MD, Pruett TL, Beilman GJ, Dunn TB. The impact of using an intraoperative goal directed fluid therapy protocol on clinical outcomes in patients undergoing total pancreatectomy and islet cell autotransplantation. Pancreatology 2017; 17:586-591. [PMID: 28659243 DOI: 10.1016/j.pan.2017.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/25/2017] [Accepted: 06/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients undergoing total pancreatectomy and islet cell autotransplant (TPIAT) for treatment of pancreatitis are at risk for complications of over and under resuscitation. We hypothesized that using a goal directed fluid therapy (GDFT) protocol might impact clinical outcomes. MATERIALS AND METHODS A consecutive series of adult patients undergoing TPIAT were managed intraoperatively using either standard fluid therapy (SFT, n = 44) or GDFT (n = 23) as part of a pilot study between January 2013 and May 2015. Patient characteristics, intraoperative, and postoperative data were recorded prospectively, then retrospectively analyzed for differences between the groups. RESULTS The GDFT group had lower total fluid resuscitation (3,240 cc vs 5,173 cc, p < 0.0001) and transfusion requirements (1.0 cc/kg vs 3.3 cc/kg, p = 0.050) compared to the SFT group. The pre to postop nadir hemoglobin change was significantly less for GDFT (4.2 vs 5.1 gm/dl, p = 0.021) despite less transfusion. CONCLUSIONS Compared to SFT, using an intraoperative GDFT protocol in TPIAT patients was associated with significantly decreased intraoperative fluid resuscitation, blood transfusion and less postoperative dilutional anemia, without any difference in complications of underresuscitation. This pilot study suggests that GDFT is likely safe and further investigation is warranted.
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Affiliation(s)
- Matthew K Wagar
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Josh Magnuson
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Patty T Liu
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Varvara Kirchner
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Joshua J Wilhelm
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Melena D Bellin
- Division of Endocrinology, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States
| | - Ty B Dunn
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, United States.
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22
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Joosten A, Delaporte A, Cannesson M, Rinehart J, Dewilde JP, Van Obbergh L, Barvais L. Fully Automated Anesthesia and Fluid Management Using Multiple Physiologic Closed-Loop Systems in a Patient Undergoing High-Risk Surgery. ACTA ACUST UNITED AC 2017; 7:260-265. [PMID: 27669030 DOI: 10.1213/xaa.0000000000000405] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Automated delivery of anesthesia guided by processed electroencephalogram monitoring using a closed-loop system is no longer a novel concept. However, combining multiple independent physiologic closed-loop systems together has never been documented before. The purpose of this case report was to evaluate the feasibility of automated anesthesia and fluid management based on a combination of physiological variables (bispectral index, stroke volume, and stroke volume variations) using 2 independent closed-loop systems.
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Affiliation(s)
- Alexandre Joosten
- From the *Department of Anesthesiology and Perioperative Care, CUB Erasme, Université Libre de Bruxelles, Brussels, Belgium; †Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California; ‡Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California; and §Department of Vascular Surgery, CUB Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Haemodynamic coherence in perioperative setting. Best Pract Res Clin Anaesthesiol 2016; 30:445-452. [PMID: 27931648 DOI: 10.1016/j.bpa.2016.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 11/23/2022]
Abstract
Over the last decade, there has been an increased interest in the use of goal-directed therapy (GDT) in patients undergoing high-risk surgery, and various haemodynamic monitoring tools have been developed to guide perioperative care. Both the complexity of the patient and surgical procedure need to be considered when deciding whether GDT will be beneficial. Ensuring optimum tissue perfusion is paramount in the perioperative period and relies on the coherence between both macrovascular and microvascular circulations. Although global haemodynamic parameters may be optimised with the use of GDT, microvascular impairment can still persist. This review will provide an overview of both haemodynamic optimisation and microvascular assessment in the perioperative period.
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Bartels K, Esper SA, Thiele RH. Blood Pressure Monitoring for the Anesthesiologist. Anesth Analg 2016; 122:1866-79. [DOI: 10.1213/ane.0000000000001340] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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The perioperative surgical home: An innovative, patient-centred and cost-effective perioperative care model. Anaesth Crit Care Pain Med 2015; 35:59-66. [PMID: 26613678 DOI: 10.1016/j.accpm.2015.08.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/29/2015] [Accepted: 08/02/2015] [Indexed: 02/06/2023]
Abstract
Contrary to the intraoperative period, the current perioperative environment is known to be fragmented and expensive. One of the potential solutions to this problem is the newly proposed perioperative surgical home (PSH) model of care. The PSH is a patient-centred micro healthcare system, which begins at the time the decision for surgery is made, is continuous through the perioperative period and concludes 30 days after discharge from the hospital. The model is based on multidisciplinary involvement: coordination of care, consistent application of best evidence/best practice protocols, full transparency with continuous monitoring and reporting of safety, quality, and cost data to optimize and decrease variation in care practices. To reduce said variation in care, the entire continuum of the perioperative process must evolve into a unique care environment handled by one perioperative team and coordinated by a leader. Anaesthesiologists are ideally positioned to lead this new model and thus significantly contribute to the highest standards in transitional medicine. The unique characteristics that place Anaesthesiologists in this framework include their systematic role in hospitals (as coordinators between patients/medical staff and institutions), the culture of safety and health care metrics innate to the specialty, and a significant role in the preoperative evaluation and counselling process, making them ideal leaders in perioperative medicine.
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Joosten A, Alexander B, Cannesson M. Defining goals of resuscitation in the critically ill patient. Crit Care Clin 2015; 31:113-32. [PMID: 25435481 DOI: 10.1016/j.ccc.2014.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is still no "universal" consensus on an optimal endpoint for goal directed therapy (GDT) in the critically ill patient. As in other areas of medicine, this should help providers to focus on a more "individualized approach" rather than a protocolized approach to ensure proper patient care. Hemodynamic optimization needs more than simply blood pressure, heart rate, central venous pressure and urine output monitoring. It is essential to also monitor flow variables (cardiac output/stroke volume) and dynamic parameters of fluid responsiveness whenever available. This article will provide a review of current and trending approaches of the goals of resuscitation in the critically ill patient.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA; Department of Anesthesiology and Critical Care, Erasme University Hospital, Free University of Brussels, 808 Lennick Road, Brussels 1070, Belgium
| | - Brenton Alexander
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA.
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Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) 2015; 4:3. [PMID: 25897397 PMCID: PMC4403901 DOI: 10.1186/s13741-015-0014-z] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered. METHODS Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them. RESULTS The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration. CONCLUSIONS We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.
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Joosten A, Rinehart J, Cannesson M. Perioperative goal directed therapy: evidence and compliance are two sides of the same coin. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:181-183. [PMID: 25744652 DOI: 10.1016/j.redar.2015.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 01/19/2015] [Accepted: 01/23/2015] [Indexed: 06/04/2023]
Affiliation(s)
- A Joosten
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 101 South City Drive, Orange, CA 92868, USA; Department of Anesthesiology and Perioperative Care, Erasme University Hospital, Free University of Brussels, 808 Route de Lennick, 1070 Brussels, Belgium
| | - J Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 101 South City Drive, Orange, CA 92868, USA
| | - M Cannesson
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 101 South City Drive, Orange, CA 92868, USA.
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Closed-loop assisted versus manual goal-directed fluid therapy during high-risk abdominal surgery: a case-control study with propensity matching. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:94. [PMID: 25888403 PMCID: PMC4372998 DOI: 10.1186/s13054-015-0827-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 02/19/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%. METHODS Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias. RESULTS A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, P =0.008). There was no difference in case mean or final stroke volume index (45 ± 10 versus 43 ± 9 and 45 ± 11 versus 42 ± 11, respectively) or mean arterial pressure (79 ± 8 versus 83 ± 9). Case end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 versus 88 ± 13, P =0.003). CONCLUSION In this case-control study with propensity matching, clinician use of closed-loop assistance resulted in a greater portion of case time spent in a preload-independent state throughout surgery compared with manual delivery of goal-directed fluid therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02020863. Registered 19 December 2013.
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Joosten A, Huynh T, Suehiro K, Canales C, Cannesson M, Rinehart J. Goal-Directed fluid therapy with closed-loop assistance during moderate risk surgery using noninvasive cardiac output monitoring: A pilot study. Br J Anaesth 2015; 114:886-92. [PMID: 25690834 DOI: 10.1093/bja/aev002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Goal directed fluid therapy (GDFT) has been shown to improve outcomes in moderate to high-risk surgery. However, most of the present GDFT protocols based on cardiac output optimization use invasive devices and the protocols may require significant practitioner attention and intervention to apply them accurately. The aim of this prospective pilot study was to evaluate the clinical feasibility of GDFT using a closed-loop fluid administration system with a non-invasive cardiac output monitoring device (Nexfin™, BMEYE, Amsterdam, Netherlands). METHODS Patients scheduled for elective moderate risk surgery under general anaesthesia were enrolled. The primary anaesthesia team managing the case selected GDFT targets using the controller interface and all patients received a baseline 3 ml kg(-1) h(-1) crystalloid infusion. Colloid solutions were delivered by the closed-loop system for intravascular volume expansion using data from the Nexfin™ monitor. Compliance with GDFT management was defined as acceptable when a patient spent more than 85% of the surgery time in a preload independent state (defined as pulse pressure variation <13%) or when average cardiac index during surgery was >2.5 litre min(-1) m(-2). RESULTS A total of 13 patients were included in the study group. All patients met the established criteria for delivery of GDFT for greater than 85% of case time. The median length of stay in the hospital was 5 [3-6] days. CONCLUSION In this pilot study, GDFT management using the closed-loop fluid administration system with a non-invasive CO monitoring device was feasible and maintained a high rate of protocol compliance. CLINICAL TRIAL REGISTRATION NCT02020863.
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Affiliation(s)
- A Joosten
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA Department of Anesthesiology and Critical Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium
| | - T Huynh
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - K Suehiro
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - C Canales
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - M Cannesson
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - J Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
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Ripollés Melchor J, Espinosa A. [Goal directed fluid therapy controversies in non-cardiac surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:477-480. [PMID: 25284819 DOI: 10.1016/j.redar.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 06/03/2023]
Affiliation(s)
- J Ripollés Melchor
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, España.
| | - A Espinosa
- Department of Anesthesia, Blekinge County Council Hospital, Karlskrona, Suecia
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Affiliation(s)
- Nathan H Waldron
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Timothy E Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Tong J Gan
- Department of Anesthesiology, Duke University, Durham, North Carolina.
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Banh E, Wu WD, Rinehart J. Principles of pharmacologic hemodynamic management and closed-loop systems. Best Pract Res Clin Anaesthesiol 2014; 28:453-62. [PMID: 25480774 DOI: 10.1016/j.bpa.2014.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 01/30/2023]
Abstract
Every day, physicians in critical-care settings are challenged with the hemodynamic management of patients with severe cardiovascular derangements. There is a potential role for closed-loop (automated) systems to assist clinicians in managing these patients and growing interest in the possible applications. In this review, we discuss the basic principles of critical-care hemodynamic management and the closed-loop systems that have been developed to help in this setting.
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Affiliation(s)
- Esther Banh
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Wei Der Wu
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA.
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[Closed loop goal directed fluid therapy: anesthesia still has a lot to learn from aviation]. ACTA ACUST UNITED AC 2014; 33:551-2. [PMID: 25148719 DOI: 10.1016/j.annfar.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Suehiro K, Joosten A, Alexander B, Cannesson M. Guiding Goal-Directed Therapy. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0074-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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