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      Monitoring in the Intensive Care Unit: Its Past, Present, and Future

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          Abstract

          Monitoring in the critical care setting has dramatically improved during the past 50 years and has contributed significantly toimprove patients' safety and outcome [1–3]. New technologies have allowed the transfer ofadvances in biology, physiology, and bioengineering to the bedside to support data drivendecision making and continuous monitoring of the vulnerable critically ill patients.The most striking advances include the continuous and noninvasive measurement of oxygen saturation by pulseoximeters and of end tidal CO2 and the real-time displays of flow, volume, pressure time curves, and derived measures by modern ventilators as well as the development invasive and more recently noninvasive devices that provide beat-to-beat arterial pressure, stroke volume, and cardiac output monitoring. Despite these advances and the apparent impact made on patients' outcome, there are still a lot of progress to be made to bring monitoring to the level of safety and reliability achieved by industries such as aviation [3, 4]. The future of monitoring in the critical care setting probably relies less on global appraisal of descriptive variables and more on functional monitoring of organs. Ultimately monitoring complex organ function is more informative and will likely be more important than global and/or regional physiological parameterssuch as organs perfusion and oxygenation. Metabolic monitoring, reflecting the biologic functions of the organs, starts to emerge [5]. Noninvasive monitors and trend analysis will obviously continue to grow. In addition, more advanced monitoring of pain, sleep, wakefulness, and delirium are very much needed.Atthe end of the day, decision support systems and automated system will become instrumental and central in daily monitoring when such system can provide the high level of accuracy needed to allow health care providers to rely on them [6, 7]. In addition, decision support systems willonly make sense if they improveclinicians' decision making, not if they just synthesized clinical algorithms. We expect that decision support software that integrates monitoring signals to raise the safety, reliability, and efficiency bar and not to fully replace human being. Finally, there is still a lot to be learned regarding identifying which variables should be monitored to impact outcome and what constitute an appropriate as oppose to pathological harmful one to critical illnesses. Without such understanding, enhanced monitoring has the potential to lead to costly and counterproductive interventions. Finally, one has to ask whether new monitoring technologies must be evaluated and clearly demonstrate a positive impact on outcome before being used. There is no easy and universal answer to this question, we believe. Most hospital administrators may require outcome data before purchasing any new and potentially expensive technologies. This approach could, however, delay the implementation of useful technologies. It is indeed possible and likely that initial studies, even when well conducted, could only show no impact on outcome [8]. As an example, the pulse oximeter has been shown to have no impact on patients outcome [9, 10] despite the fact that this is considered standard of care. While some in the medical community are still wondering whether pulse oximeters do improve outcome since the data is lacking, in other industries such as aviation evidence-based data before implementing new technologies (monitors, autopilot, simulation) is not required and this industry has now reached an unmatched level of safety. On the other end, a more thoughtful assessment of clinical indication and physician education of physicians regarding Swan-Ganz catheter and hemodynamic management would have prevented many unhelpful right heart catheter placement over decades and possible harm. Clearly, there is not a single simple answer for every technology and/or problem at hand. In conclusion, monitoring in our specialty has come a long way. We are, however, still facing difficult challenges and the future holds great promisesfor our patient [3], particularly if, as an scientific community, we can learn from our past mistakes.This special issue on monitoring of critical patients illustrates some of the current and future challenges we are facing. Maxime  Cannesson Alain  Broccard Benoit  Vallet Karim  Bendjelid

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          Most cited references16

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          The future of health information technology in the patient-centered medical home.

          Most electronic health records today need further development of features that patient-centered medical homes require to improve their efficiency, quality, and safety. We propose a road map of the domains that need to be addressed to achieve these results. We believe that the development of electronic health records will be critical in seven major areas: telehealth, measurement of quality and efficiency, care transitions, personal health records, and, most important, registries, team care, and clinical decision support for chronic diseases. To encourage this development, policy makers should include medical homes in emerging electronic health record regulations. Additionally, more research is needed to learn how these records can enhance team care.
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            Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications.

            The authors describe the effect of pulse oximetry monitoring on the frequency of unanticipated perioperative events, changes in patient care, and the rate of postoperative complications in a prospective randomized study. The study included 20,802 surgical patients in Denmark randomly assigned to be monitored or not with pulse oximetry in the operating room (OR) and postanesthesia care unit (PACU). During anesthesia and in the PACU, significantly more patients in the oximetry group had at least one respiratory event than did the control patients. This was the result of a 19-fold increase in the incidence of diagnosed hypoxemia in the oximetry group than in the control group in both the OR and PACU (P < 0.00001). In the OR, cardiovascular events were observed in a similar number of patients in both groups, except myocardial ischemia (as defined by angina or ST-segment depression), which was detected in 12 patients in the oximetry group and in 26 patients in the control group (P < 0.03). Several changes in PACU care were observed in association with the use of pulse oximetry. These included higher flow rate of supplemental oxygen (P < 0.00001), increased use of supplemental oxygen at discharge (P < 0.00001), and increased use of naloxone (P < 0.02). The rate of changes in patient care as a consequence of the oximetry monitoring increased as the American Society of Anesthesiologists physical status worsened (P < 0.00001). One or more postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group (difference not significant). The two groups did not differ significantly in cardiovascular, respiratory, neurologic, or infectious complications. The duration of hospital stay was a median of 5 days in both groups (difference not significant). An equal number of inhospital deaths were registered in the two groups. Questionnaires, completed by the anesthesiologists at the five participating departments, revealed that 18% of the anesthesiologists had experienced a situation in which a pulse oximeter helped to avoid a serious event or complication and that 80% of the anesthesiologists felt more secure when they used a pulse oximeter. This study demonstrated that pulse oximetry can improve the anesthesiologist's ability to detect hypoxemia and related events in the OR and PACU and that the use of the oximeter was associated with a significant decrease in the rate of myocardial ischemia. Although monitoring with pulse oximetry prompted a number of changes in patient care, a reduction in the overall rate of postoperative complications was not observed.
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              Randomized Evaluation of Pulse Oximetry in 20,802 Patients; II

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                Author and article information

                Journal
                Crit Care Res Pract
                Crit Care Res Pract
                CCRP
                Critical Care Research and Practice
                Hindawi Publishing Corporation
                2090-1305
                2090-1313
                2012
                17 September 2012
                : 2012
                : 452769
                Affiliations
                1Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA 92697, USA
                2Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55435-2199, USA
                3Department of Anesthesiology and Critical Care Medicine, University Hospital of Lille Nord de France, 59037 Lille, France
                4Intensive Care Division, Geneva Medical School, Geneva University Hospitals, 1211 Geneva 14, Switzerland
                Author notes
                Article
                10.1155/2012/452769
                3457610
                23019523
                7fa3d921-3a04-4204-9207-de9c6f3d5a4f
                Copyright © 2012 Maxime Cannesson et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 27 June 2012
                : 27 June 2012
                Categories
                Editorial

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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