| Despite the plethora of electronic devices and monitoring systems that exists today in the Cardiovascular Intensive Care Unit (CVICU), most hemodynamic management decisions are still intuitive and manually driven. Unfortunately, the massive volume of physiologic data from these post-operative cardiac patients can create information overload, impairing effective decision-making. At the same time, practice variations among CVICU physicians have rendered it difficult to assess the effectiveness of the therapeutic interventions.;This dissertation describes the development and validation of a decision-support system prototype that can help manage hypotension associated with hypovolemia in CVICU patients. The hypothesis was: expertise in hemodynamic management can be formalized as computer-based protocols that can provide therapeutic recommendations significantly more consistent with clinical management goals than occurs with current practice. Limited resources constrained the research to hypovolemic-hypotension, and to retrospective analysis of historical cases, also to modeling rather than a real-time system.;The prototype uses physiologic pattern-matching, therapeutic protocols, computational drug-dosage response modeling and expert reasoning heuristics in the selection of intervention strategies and choices. The protocols were formalized through consensus by four expert CVICU physicians. Other knowledge sources were textbooks and detailed critical review by two of the physicians of 13 historical CVICU cases with 410 interventions. The prototype used a monitoring approach, simulating real-time operation by processing the historical physiologic and intervention data on a patient sequentially, generating alerts on questionable data, critiques of interventions instituted and recommendations on preferred interventions. Bench-testing used another 13 historical cases with 399 interventions, each case critically reviewed to identify the preferred interventions reflective of clinical management goals. The testing, applied equally to the prototype's proposals and to the actual history, showed the therapies for bleeding and fluid replacement proposed by the prototype were significantly better (p ;This study has demonstrated the feasibility of formalizing hemodynamic management of CVICU patients in a manner that may be implemented in a clinical setting. The introduction of this type of computer-based decision-support tool is timely, as there has been an increasing effort from the medical community to establish standards for the delivery and assessment of patient care to improve its quality and outcome. Such effort can be aided by this type of system, which can provide the necessary patient data and practice guidelines to conduct formal scientific evaluations in a systematic fashion. |
