Point of Care management using technology · Point of Care management using technology Dr S Omar...
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Point of Care management using technology
Dr S Omar
Chris Hani Baragwanath Academic Hospital
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What is Point of Care (POC)?
• A laboratory diagnostic test performed at or near the site where clinical care is delivered..
Point of Care testing. Nichols et al. Clin Lab Med 27 (2007)
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Technological advances
• The term point-of-care testing (POCT) refers to any diagnostic test performed at or near the location of the patient.
Larsson et al, Upsala Journal of Medical Sciences. 2015; 120: 1–10
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Xu, X., Ding, W., Wang, X., Cao, R., Zhang, M., Lv, P., Xu, F., 2016. Smartphone-Based Accurate Analysis of Retinal Vasculature towards Point-of-Care Diagnostics. Scientific Reports 6, 34603.
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• All have some common concepts:
–Used at/near patient
–No permanent dedicated space required
– Entire process – test, result, interpretation, Mx decision occur at the/near patient
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Is it useful?
• Satisfactory correlation when similar technologies used.
• POCT decreases the time to decisions on patient management
• POCT has the potential to provide beneficial patient outcome
• Has become standard of care in many areas
Pecoraro, V., Germagnoli, L., Banfi, G., 2014. Point-of-care testing: where is the evidence? A systematic survey. Clin. Chem. Lab. Med. 52, 313–324. doi:10.1515/cclm-2013-0386
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Interesting concept to using big data for POC Mx
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Monte Carlo method
• Computational power of a computer to predict outcomes with many influences
• Define a domain of possible inputs.
• Generate inputs randomly from a probability distribution over the domain.
• Perform a deterministic computation on the inputs.
• Aggregate the results.
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Problem?
• Strong relationship between adequate antibiotic exposure, bacterial killing and clinical cure.
• Adequate antibiotic exposure is a real challenge in the ICU
• Numerous reasons
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Why is the Vd so different
Free Drug
Albumin
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Inflammation Ischemia reperfusionHypervolemiaStarches?
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Changes in Vd
• Critical illness
– Capillary leak syndrome
– Decrease in Albumin
– Decreased binding to Alb
• AKI
– Vol changes
– Clearance changes
– pH/Uraemia
Fissel et al Adv Chronic Kidney Ds, 2013Choi et al CCM, 2010
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Additional dosesExtended infusionsContinuous infusions
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We need to know fancy pharmacology
• C = D / V and D = C x V
• Concentration - 5 X 4mg/L (MIC) = 20mg/L
• Volume of distribution = 0.38L/kg x 80kg = 30L
• Dose required = 20mg/L x 30L = 600mg
Load with 600 mg to achieve a targetconcentration of 20mg/L
Choi et al Blood Purification,2010
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64
32
8
4
=8.4 hours
4 x T1/2 to 2mg/L33.6 hours to 2mg/L
2
4
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Log on patient and conditions
Match in the “Heavens”
Predicted dose
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POC “PK/PD dosing
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We’re testing a simplified version
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Second challenge
• Delays to theatre and interventional procedures because of delays immediate platelet count availability
• Delays in antibiotic therapy because becauseof similar issues with WCC
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Common challenges with POC :
Barriers to Implementation of Rapid and Point-of-Care Tests for Human Immunodeficiency Virus Infection Findings From a Systematic Review (1996–2014)Nitika Pant Pai, MD, MPH, PhD, Samantha Wilkinson, MSc, [...], and Tom Wong, MD, MPH, FRCPC
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Easy enough to be accurately performed by : Doctors and non medical ICU staff
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Technical review checklist
1. Involve local institution2. Mx3. Health and safety4. Training5. Instructions6. SOP7. Quality Mx8. Results reviewed by appropriate persons9. Record keeping10. Maintenance
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Moderately complex POC equipment
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Differences in results ?
• Laboratory trained – pathologist
• Doctor
• Non medical (Clerk)
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Path vs Doctor –Mann WhitneyHb N Median 25th 75th p
Path 87 9.4 8.3 10.0 >0.05
Doctor 63 8.9 8.0 9.9 No diff
WCC N Median 25th 75th p
Path 56 11.1 8.1 16.35 >0.05
Doctor 35 12.3 8.6 19.3 No diff
Plat N Median 25th 75th p
Path 76 235.5 147 422.5 >0.05
Doctor 55 204 112 323 No diff
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Clerk vs Doctor- Mann WhitneyHb N Median 25th 75th p
Clerk 152 9.0 8.1 10.15 P>0.05
Doctor 63 8.9 8.0 9.9 No diff
WCC N Median 25th 75th p
Clerk 108 11.8 7.75 17.85 >0.05
Doctor 53 12.3 8.6 19.3 No diff
Plat N Median 25th 75th p
Clerk 145 229 149 354 >0.05
Doctor 55 204 112 323 No diff
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POCUS for Fluid Mx
CCM 2016
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Passive leg raise test
SV = 40ml
SV = 50ml
Increase in SV = 50-40 /40= 25%
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For some Tea