Critical care, like many healthcare areas, is under a dual assault from significantly increasing demographic and economic pressures. Intensive care unit (ICU) patients are highly variable in response ...to treatment, and increasingly aging populations mean ICUs are under increasing demand and their cohorts are increasingly ill. Equally, patient expectations are growing, while the economic ability to deliver care to all is declining. Better, more productive care is thus the big challenge. One means to that end is personalised care designed to manage the significant inter- and intra-patient variability that makes the ICU patient difficult. Thus, moving from current "one size fits all" protocolised care to adaptive, model-based "one method fits all" personalised care could deliver the required step change in the quality, and simultaneously the productivity and cost, of care. Computer models of human physiology are a unique tool to personalise care, as they can couple clinical data with mathematical methods to create subject-specific models and virtual patients to design new, personalised and more optimal protocols, as well as to guide care in real-time. They rely on identifying time varying patient-specific parameters in the model that capture inter- and intra-patient variability, the difference between patients and the evolution of patient condition. Properly validated, virtual patients represent the real patients, and can be used in silico to test different protocols or interventions, or in real-time to guide care. Hence, the underlying models and methods create the foundation for next generation care, as well as a tool for safely and rapidly developing personalised treatment protocols over large virtual cohorts using virtual trials. This review examines the models and methods used to create virtual patients. Specifically, it presents the models types and structures used and the data required. It then covers how to validate the resulting virtual patients and trials, and how these virtual trials can help design and optimise clinical trial. Links between these models and higher order, more complex physiome models are also discussed. In each section, it explores the progress reported up to date, especially on core ICU therapies in glycemic, circulatory and mechanical ventilation management, where high cost and frequency of occurrence provide a significant opportunity for model-based methods to have measurable clinical and economic impact. The outcomes are readily generalised to other areas of medical care.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Intensive insulin therapy (IIT) and tight glycaemic control (TGC), particularly in intensive care unit (ICU), are the subjects of increasing and controversial debate in recent years. ...Model-based TGC has shown potential in delivering safe and tight glycaemic management, all the while limiting hypoglycaemia. A comprehensive, more physiologically relevant Intensive Control Insulin-Nutrition-Glucose (ICING) model is presented and validated using data from critically ill patients. Two existing glucose–insulin models are reviewed and formed the basis for the ICING model. Model limitations are discussed with respect to relevant physiology, pharmacodynamics and TGC practicality. Model identifiability issues are carefully considered for clinical settings. This article also contains significant reference to relevant physiology and clinical literature, as well as some references to the modeling efforts in this field. Identification of critical constant population parameters was performed in two stages, thus addressing model identifiability issues. Model predictive performance is the primary factor for optimizing population parameter values. The use of population values are necessary due to the limited clinical data available at the bedside in the clinical control scenario. Insulin sensitivity, S I , the only dynamic, time-varying parameter, is identified hourly for each individual. All population parameters are justified physiologically and with respect to values reported in the clinical literature. A parameter sensitivity study confirms the validity of limiting time-varying parameters to S I only, as well as the choices for the population parameters. The ICING model achieves median fitting error of <1% over data from 173 patients ( N = 42,941 h in total) who received insulin while in the ICU and stayed for ≥72 h. Most importantly, the median per-patient 1-h ahead prediction error is a very low 2.80% IQR 1.18, 6.41%. It is significant that the 75th percentile prediction error is within the lower bound of typical glucometer measurement errors of 7–12%. These results confirm that the ICING model is suitable for developing model-based insulin therapies, and capable of delivering real-time model-based TGC with a very tight prediction error range. Finally, the detailed examination and discussion of issues surrounding model-based TGC and existing glucose–insulin models render this article a mini-review of the state of model-based TGC in critical care.
Background
The changes in metabolic pathways and metabolites due to critical illness result in a highly complex and dynamic metabolic state, making safe, effective management of hyperglycemia and ...hypoglycemia difficult. In addition, clinical practices can vary significantly, thus making GC protocols difficult to generalize across units.The aim of this study was to provide a retrospective analysis of the safety, performance and workload of the stochastic targeted (STAR) glycemic control (GC) protocol to demonstrate that patient-specific, safe, effective GC is possible with the STAR protocol and that it is also generalizable across/over different units and clinical practices.
Methods
Retrospective analysis of STAR GC in the Christchurch Hospital Intensive Care Unit (ICU), New Zealand (267 patients), and the Gyula Hospital, Hungary (47 patients), is analyzed (2011–2015). STAR Christchurch (BG target 4.4–8.0 mmol/L) is also compared to the Specialized Relative Insulin and Nutrition Tables (SPRINT) protocol (BG target 4.4–6.1 mmol/L) implemented in the Christchurch Hospital ICU, New Zealand (292 patients, 2005–2007). Cohort mortality, effectiveness and safety of glycemic control and nutrition delivered are compared using nonparametric statistics.
Results
Both STAR implementations and SPRINT resulted in over 86 % of time per episode in the blood glucose (BG) band of 4.4–8.0 mmol/L. Patients treated using STAR in Christchurch ICU spent 36.7 % less time on protocol and were fed significantly more than those treated with SPRINT (73 vs. 86 % of caloric target). The results from STAR in both Christchurch and Gyula were very similar, with the BG distributions being almost identical. STAR provided safe GC with very few patients experiencing severe hypoglycemia (BG < 2.2 mmol/L, <5 patients, 1.5 %).
Conclusions
STAR outperformed its predecessor, SPRINT, by providing higher nutrition and equally safe, effective control for all the days of patient stay, while lowering the number of measurements and interventions required. The STAR protocol has the ability to deliver high performance and high safety across patient types, time, clinical practice culture (Christchurch and Gyula) and clinical resources.
Identification of end systole is often necessary when studying events specific to systole or diastole, for example, models that estimate cardiac function and systolic time intervals like left ...ventricular ejection duration. In proximal arterial pressure waveforms, such as from the aorta, the dicrotic notch marks this transition from systole to diastole. However, distal arterial pressure measures are more common in a clinical setting, typically containing no dicrotic notch. This study defines a new end systole detection algorithm, for dicrotic notch-less arterial waveforms. The new algorithm utilises the beta distribution probability density function as a weighting function, which is adaptive based on previous heartbeats end systole locations. Its accuracy is compared with an existing end systole estimation method, on dicrotic notch-less distal pressure waveforms. Because there are no dicrotic notches defining end systole, validating which method performed better is more difficult. Thus, a validation method is developed using dicrotic notch locations from simultaneously measured aortic pressure, forward projected by pulse transit time (PTT) to the more distal pressure signal. Systolic durations, estimated by each of the end systole estimates, are then compared to the validation systolic duration provided by the PTT based end systole point. Data comes from ten pigs, across two protocols testing the algorithms under different hemodynamic states. The resulting mean difference ± limits of agreement between measured and estimated systolic duration, of
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8.7
±
26.6
ms
versus
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23.2
±
37.7
ms
, for the new and existing algorithms respectively, indicate the new algorithms superiority.
Background: Elevated blood glucose (BG) concentrations (Hyperglycaemia) are a common complication in critically ill patients. Insulin therapy is commonly used to treat hyperglycaemia, but metabolic ...variability often results in poor BG control and low BG (hypoglycaemia). Objective: This paper presents a model-based virtual trial method for glycaemic control protocol design, and evaluates its generalisability across different populations. Methods: Model-based insulin sensitivity (SI) was used to create virtual patients from clinical data from three different ICUs in New Zealand, Hungary, and Belgium. Glycaemic results from simulation of virtual patients under their original protocol (self-simulation) and protocols from other units (cross simulation) were compared. Results: Differences were found between the three cohorts in median SI and inter-patient variability in SI. However, hour-to-hour intra-patient variability in SI was found to be consistent between cohorts. Self and cross-simulation results were found to have overall similarity and consistency, though results may differ in the first 24-48 h due to different cohort starting BG and underlying SI. Conclusions and Significance: Virtual patients and the virtual trial method were found to be generalisable across different ICUs. This virtual trial method is useful for in silico protocol design and testing, given an understanding of the underlying assumptions and limitations of this method.
This paper presents a new structural health monitoring (SHM) method using frequency-modulated continuous wave (FMCW) radar. The method was developed to circumvent issues with SHM methods' need for ...displacement measurements, which can be difficult to obtain robustly through integrated accelerations, or through other displacement measurement methods. Instead, interstorey drift ratios (IDRs) were estimated through the direct measurement of interstorey displacement using FMCW radar. Simulation of this method using historical structural response data verified suitably accurate displacement measurements could be obtained using FMCW radar, and prompted the construction of a prototype system. Experimental validation of this prototype was carried out on a shake table. The precision of the system in terms of mean IDR was found to be 1.09 × 10 -3 . These results are encouraging for the future deployment of this SHM approach.
There is an increasingly urgent need for humans to interactively control robotic systems to perform increasingly precise remote operations, concomitant with the rapid development of space ...exploration, deep-sea discovery, nuclear rehabilitation and management, and robotic-assisted medical devices. The potential high value of medical telerobotic applications was also evident during the recent coronavirus pandemic and will grow in future. Robotic teleoperation satisfies the demands of the scenarios in which human access carries measurable risk, but human intelligence is required. An effective teleoperation system not only enables intuitive human-robot interaction (HRI) but ensures the robot can also be operated in a way that allows the operator to experience the “feel” of the robot working on the remote side, gaining a “sense of presence”. Extended reality (XR) technology integrates real-world information with computer-generated graphics and has the potential to enhance the effectiveness and performance of HRI by providing depth perception and enabling judgment and decision making while operating the robot in a dynamic environment. This review examines novel approaches to the development and evaluation of an XR-enhanced telerobotic platform for intuitive remote teleoperation applications in dangerous and difficult working conditions. It presents a strong review of XR-enhanced telerobotics for remote robotic applications; a particular focus of the review includes the use of integrated 2D/3D mixed reality with haptic interfaces to perform intuitive remote operations to remove humans from dangerous conditions. This review also covers primary studies proposing Virtual Reality (VR), Augmented Reality (AR), and Mixed Reality (MR) solutions where humans can better control or interact with real robotic platforms using these devices and systems to extend the user’s reality and provide a more intuitive interface. The objective of this article is to present recent, relevant, common, and accessible frameworks implemented in research articles published on XR-enhanced telerobotics for industrial applications. Finally, we present and classify the application context of the reviewed articles in two groups: mixed reality–enhanced robotic telemanipulation and mixed reality–enhanced robotic tele-welding. The review thus addresses all elements in the state of the art for these systems and ends with recommended research areas and targets. The application range of these systems and the resulting recommendations is readily extensible to other application areas, such as remote robotic surgery in telemedicine, where surgeons are scarce and need is high, and other potentially high-risk/high-need scenarios.
•Dynamically identified tube-load model for pulse contour analysis, accounting for arterial wave reflection.•Validation during clinically relevant recruitment manoeuvre, fluid administration, and ...induced septic shock interventions.•Tube-load model provides physiologically realistic central pressure and flow waveform estimates, and reasonable cardiac stroke volume estimation.
Background and Objectives: Accurate, reproducible, and reliable real-time clinical measurement of stroke volume (SV) is challenging. To accurately estimate arterial mechanics and SV by pulse contour analysis, accounting for wave reflection, such as by a tube-load model, is potentially important. This study tests for the first time whether a dynamically identified tube-load model, given a single peripheral arterial input signal and pulse transit time (PTT), provides accurate SV estimates during hemodynamic instability.
Methods: The model is tested for 5 pigs during hemodynamic interventions, using either an aortic flow probe or admittance catheter for a validation SV measure. Performance is assessed using Bland-Altman and polar plot analysis for a series of long-term state-change and short-term dynamic events.
Results:The overall median bias and limits of agreement (2.5th, 97.5th percentile) from Bland-Altman analysis were -10% -49, 36, and -1% -28,20 for state-change and dynamic events, respectively. The angular limit of agreement (maximum of 2.5th, 97.5th percentile) from polar-plot analysis for state-change and dynamic interventions was 35.6∘, and 35.2∘, respectively.
Conclusion: SV estimation agreement and trending performance was reasonable given the severity of the interventions. This simple yet robust method has potential to track SV within acceptable limits during hemodynamic instability in critically ill patients, provided a sufficiently accurate PTT measure.
Abstract Tight glycemic control (TGC) has emerged as a major research focus in critical care due to its potential to simultaneously reduce both mortality and costs. However, repeating initial ...successful TGC trials that reduced mortality and other outcomes has proven difficult with more failures than successes. Hence, there has been growing debate over the necessity of TGC, its goals, the risk of severe hypoglycemia, and target cohorts. This paper provides a review of TGC via new analyses of data from several clinical trials, including SPRINT, Glucontrol and a recent NICU study. It thus provides both a review of the problem and major background factors driving it, as well as a novel model-based analysis designed to examine these dynamics from a new perspective. Using these clinical results and analysis, the goal is to develop new insights that shed greater light on the leading factors that make TGC difficult and inconsistent, as well as the requirements they thus impose on the design and implementation of TGC protocols. A model-based analysis of insulin sensitivity using data from three different critical care units, comprising over 75,000 h of clinical data, is used to analyse variability in metabolic dynamics using a clinically validated model-based insulin sensitivity metric ( S I ). Variation in S I provides a new interpretation and explanation for the variable results seen (across cohorts and studies) in applying TGC. In particular, significant intra- and inter-patient variability in insulin resistance (1/ S I ) is seen be a major confounder that makes TGC difficult over diverse cohorts, yielding variable results over many published studies and protocols. Further factors that exacerbate this variability in glycemic outcome are found to include measurement frequency and whether a protocol is blind to carbohydrate administration.
Background
Hyperglycaemia is commonplace in the adult intensive care unit (ICU), associated with increased morbidity and mortality. Effective glycaemic control (GC) can reduce morbidity and ...mortality, but has proven difficult. STAR is a proven, effective model-based ICU GC protocol that uniquely maintains normo-glycaemia by changing both insulin and nutrition interventions to maximise nutrition in the context of GC in the 4.4–8.0 mmol/L range. Hence, the level of nutrition it provides is a time-varying estimate of the patient-specific ability to take up glucose.
Methods
First, the clinical provision of nutrition by STAR in Christchurch Hospital, New Zealand (
N
= 221 Patients) is evaluated versus other ICUs, based on the Cahill et al. survey of 158 ICUs. Second, the inter- and intra- patient variation of nutrition delivery with STAR is analysed. Nutrition rates are in terms of percentage of caloric goal achieved.
Results
Mean nutrition rates clinically achieved by STAR were significantly higher than the mean and best ICU surveyed, for the first 3 days of ICU stay. There was large inter-patient variation in nutrition rates achieved per day, which reduced overtime as patient-specific metabolic state stabilised. Median intra-patient variation was 12.9%; however, the interquartile range of the mean per-patient nutrition rates achieved was 74.3–98.2%, suggesting patients do not deviate much from their mean patient-specific nutrition rate. Thus, the ability to tolerate glucose intake varies significantly between, rather than within, patients.
Conclusions
Overall, STAR’s protocol-driven changes in nutrition rate provide higher nutrition rates to hyperglycaemic patients than those of 158 ICUs from 20 countries. There is significant inter-patient variability between patients to tolerate and uptake glucose, where intra-patient variability over stay is much lower. Thus, a best nutrition rate is likely patient specific for patients requiring GC. More importantly, these overall outcomes show high nutrition delivery and safe, effective GC are not exclusive and that restricting nutrition for GC does not limit overall nutritional intake compared to other ICUs.
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