Using histogram and event review feature on multichannel monitors to improve point of care decision making in NICU

Transcription

1 Using histogram and event review feature on multichannel monitors to improve point of care decision making in NICU Sandesh Shivananda Associate Professor, Medical Director University of British Columbia, Canada Feb 6, 2018

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3 Swinging Dippy Events Apnea Bradycardia Desaturation ABD Spells

4 Neonatal events Bradycardia-----HR < 100 Desaturation----SpO 2 < 88% for 10 sec Apnea Cessation of breathing for >/= 20 sec

5 Association between oxygen saturation, desaturation events, BPD, ROP & neurodevelopmental impairment Fluctua2on$in$satura2on$of$ O2$ Prolonged$period$of$ 2me$spent$above$or$ below$spo2$range$ Frequency$of$apnea/ desatura2on$events$ BPD$ ROP$ Mortality$ Neurodevelopmental impairment <33 weeks n=4000 infants, BPD ~ 20%, ROP ~ 10%, CNN Annual report 2012 Di Fiore, Jpeds 2010

6 Association between oxygen saturation, desaturation events, BPD, ROP & neurodevelopmental impairment Address these events effectively in real time Neurodevelopmental impairment <33 weeks n=4000 infants, BPD ~ 20%, ROP ~ 10%, CNN Annual report 2012 Di Fiore, Jpeds 2010

7 Every event needs an immediate response to address event----min to min basis [symptomatic Rx] Strategic response to address underlying cause of event hrs. basis [specific Rx]

8 Fasting glucose-----adjust dose of Plain Insulin HbA1C adjust type of hypoglycemic agent, type of Insulin event event event event event event Cumulative assessment of events to establish underlying diagnosis initiate appropriate Rx Oxygen histogram Event surveillance review feature in monitors

9 What is histogram and event review? How to access it?

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11 Graphic window

12 Table view

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18 Histogram & Event surveillance review technology reports Built in standard component of monitors Cumulative report of all all desaturation, bradycardia, apnea events Histogram of time spent within various SpO 2 ranges Solution to above problem How do we use histogram & event surveillance review reports in decision making & care planning? Innovate

19 Decision aid tools to guide decision making at bedside

20 Di Fore J Peds, Home O 2 guideline, CBIOME Pilot studies, Observation; Validation pending

21 Events classification - Ed Pugh 2014 PhD Thesis Personal communication The order with which physiological parameters change in each type of spell (HR - Heart Rate, RI Respiratory impedance, Saturations Blood Oxygen Saturation)

22 Needs Action What are the underlying causes of desaturation? What practices can I adopt to reduce desaturations and improve infant stability?

23 How do we use the ESR +ROSE tool at the bedside Monitoring & decision making? Is there any added value? Clinical X ray Blood gas FiO2 and Vent settings ESR+ROSE tool Does it help in Determining etiology? assessing response to changes in Rx/care plan? assessing overall wellness of infant? Empower frontline staff in understanding their infant Recognize changes early Handover Advocating

24 Scenario 1 Determine etiology 36 w/3kg/ late preterm, outborn in room air admitted at 3 weeks of life with recurrent bradycardia events and occasional desaturations,? Posturing episodes Provisional diagnosis Suspected GERD Mouthful, sucking movements, éburping, feeding? Is it central apnea?

25 1 2 Vagal

26 Scenario 2: Obstructive event 24 w, now 36 w PCA with Post Hemorrhagic Hydrocephalous on the day prior to VP shunt had a cluster of events (Brady, desaturation and received tactile stimulation, suctioning twice) Sunday CRP was 26, Not initiated on antibiotics DD: Sepsis, viral upper RTI Monday morning?to subject or not to OR Clinical examination normal Neurosurgery date NA for next 2 weeks

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29 Events classification - Ed Pugh 2014 PhD Thesis Personal communication The order with which physiological parameters change in each type of spell (HR - Heart Rate, RI Respiratory impedance, Saturations Blood Oxygen Saturation)

30 Scenario 5 : Assess response to slow bolus feeding 25 w, 750g, 40 days, corrected 31 wks on CPAP 5, 23% Suspect GERD changed from bolus to slow bolus over 60 minutes Is this change effective?

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32 before after Histogram <90% 27% 12% Events frequency Upsizing prongs, Increasing CPAP Positioning Post extubation stability

33 Assess the impact of interventions 31 events over 24 hrs. Before & after ROP screen eye examination 50 events over 20 hrs.

34 Event surveillance - compare your swingers by pattern recognition A B C D

35 Assessment of oxygenation maintenance using histogram, based on time spent below SpO2 of 90% (Tailing effect) <90% = 2% <90% = 22% A B <90% = 42% <90% = 60% D C

36 Histogram and event review technology ROSE tool based objective assessment Reviewing individual episodes Helpful tools at the point of care to Determine underlying etiology Initiate appropriate timely treatment Assess response to Rx Deliver Patient centered care May result in better outcomes BPD ROP NDI

37 Acknowledgement CBIOME Team (Steering, Operation, Project teams) PSI NICU leadership, communication leads NICU preemies Fellows, residents, NPs, RTs Colleagues and care providers

38 Scenario 3: 24 w/752g/85d male with BPD on LF O2, 36 week corrected Off LF O2 Unsure whether will tolerate or not?

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40 Histogram <90% 4% 20% Events frequency 6 32 Restart LFO2

41 Scenario 5 : 25 w, 750g, 40 days, corrected 31 wks on CPAP 5, 23% Suspect GERD changed from bolus to slow bolus over 60 mins Is this change effective?

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43 Histogram <90% 27% 12% Events frequency Continued on slow bolus. Off CPAP in 8 days

44 Scenario 6: Event surveillance review window and inference on severity of swings- compare your swingers A B C D

45 Scenario 7: 26w 620g, Day 76 BPD off HFO2, had bounced back from level 2 within 12 hrs with resp distress 2 weeks back Now trialed off for the second time To send to L2N or not 24 hrs off HF Observed for 3 days Tachypnea same Retractions, oral feeding FiO2, events remained same

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48 Observed in NICU over next 3 days and then sent to L2N? Compensated tachypnea Reassured frontline staff and family SpO2 Histogram, Events frequency normal 50% of time had tachypnea

49 Scenario 8: Does ROP eye screening impact infant wellness? 82% of time had tachypnea No weaning/ change of mode No change in feeding regimen on ROP screen days Is this necessary?

50 Scenario 9: 28w 1230g Day 38 Swinging infant on CPAP 7, 25-28% Reflux slow bolus All trouble shooting done None found, No improvement Mother (a nurse) reluctant to suggestion of increasing CPAP/changing to NIPPV Upsizing the prongs, same CPAP, rigorous venting Did it help?

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52 7 days later Histogram <90% 32% 10% Events frequency 50/10hrs 11/24h Wean cpap FiO2 21%

53 Scenario 10: 26w 978g Day 35, CPAP 5 Swings, events No apparent cause on examination Impact of recruiting the lung (CPAP 6), vent stomach

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55 4 days later Histogram <90% 26% 12% Effective Events frequency 50/15hrs 16

56 Scenario 11: 26w 955g Day 38 on CPAP 7 Mother (a teacher) Initially feeds made slow bolus over 90 mins No change CPAP increased to 8 Serial changes

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59 Slow bolus é CPAP Histogram <90% 45% 39 30>18% Impact of serial interventions can be assessed Events frequency 50/15hrs 50 21

60 Errors

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64 Unintended adverse decision making prevention & promoting health Bedside report CPAP 8 cm, FiO %, intermittent tachypnea, occasional desaturation, not weaned for last 2 days Decision to wean CPAP to 7 cm- not uncommon Is the infant ready? Is the infant tolerating it? Can the infant express his/her preference? EBP= Best evidence + Judgment + Patient preference Infant wellness on every single day in NICU determines long term outcome Benchmarking centers >> Benchmark against best possible wellness for that day for that infant

65 Others Convincing parents on safety of skin to skin care Confidence in using high flow vs. CPAP Compensatory respiratory distress following off CPAP Parents reporting stability

66 Acknowledgement CBIOME Team (Steering, Operation, Project teams) PSI NICU leadership, communication leads NICU preemies Fellows, residents, NPs, RTs Colleagues and care providers