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Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Alexander Roederer University of Pennsylvania, [email protected]

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Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Alexander Roederer University of Pennsylvania, Roederer@Seas.Upenn.Edu University of Pennsylvania ScholarlyCommons Departmental Papers (CIS) Department of Computer & Information Science 4-13-2015 Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Alexander Roederer University of Pennsylvania, [email protected] James Weimer University of Pennsylvania, [email protected] Joseph Dimartino University of Pennsylvania Health System, [email protected] Jacob Gutsche University of Pennsylvania Health System, [email protected] Insup Lee University of Pennsylvania, [email protected] Follow this and additional works at: http://repository.upenn.edu/cis_papers Part of the Computer Engineering Commons, and the Computer Sciences Commons Recommended Citation Alexander Roederer, James Weimer, Joseph Dimartino, Jacob Gutsche, and Insup Lee, "Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients", 6th Workshop on Medical Cyber-Physical Systems (MedicalCPS 2015) . April 2015. 6th Workshop on Medical Cyber-Physical Systems (MedicalCPS 2015) http://workshop.medcps.org/ in conjunction with CPS Week 2015 http://www.cpsweek.org/2015/ Seattle, WA, April 13, 2015 An extended version of this paper is available at http://repository.upenn.edu/cis_papers/787/ This paper is posted at ScholarlyCommons. http://repository.upenn.edu/cis_papers/781 For more information, please contact [email protected]. Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Abstract Hypovolemia caused by internal hemorrhage is a major cause of death in critical care patients. However, hypovolemia is difficult to diagnose in a timely fashion, as obvious symptoms do not manifest until patients are already nearing a critical state of shock. Novel non-invasive methods for detecting hypovolemia in the literature utilize the photoplethysmogram (PPG) waveform generated by the pulse-oximeter attached to a finger or ear. Until now, PPG-based alarms have been evaluated only on healthy patients under ideal testing scenarios (e.g., motionless patients); however, the PPG is sensitive to patient health and significant artifacts manifest when patients move. Since patient health varies within the intensive care unit (ICU) and ICU patients typically do not remain motionless, this work introduces a PPG-based monitor designed to be robust to waveform artifacts and health variability in the underlying patient population. To demonstrate the promise of our approach, we evaluate the proposed monitor on a small sample of intensive care patients from the Physionet database. The monitor detects hypovolemia within a twelve hour window of nurse documentation of hypovolemia when it is present, and achieves a low false alarm rate over patients without documented hypovolemia. Keywords Time series analysis, Medical Information Systems Disciplines Computer Engineering | Computer Sciences Comments 6th Workshop on Medical Cyber-Physical Systems (MedicalCPS 2015) http://workshop.medcps.org/ in conjunction with CPS Week 2015 http://www.cpsweek.org/2015/ Seattle, WA, April 13, 2015 An extended version of this paper is available at http://repository.upenn.edu/cis_papers/787/ This conference paper is available at ScholarlyCommons: http://repository.upenn.edu/cis_papers/781 Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients ∗ Alexander Roederer James Weimer Dept. of Computer & Dept. of Computer & Information Sc. Information Sc. University of Pennsylvania University of Pennsylvania [email protected] [email protected] Joseph Dimartino Jacob Gutsche Insup Lee Penn Presbyterian Medical Center Penn Presbyterian Medical Dept. of Computer & University of Pennsylvania Health System Center Information Sc. [email protected] University of Pennsylvania University of Pennsylvania Health System and the [email protected] Perelman School of Medicine [email protected] ABSTRACT among post-operative patients, and bleeding-related compli- Hypovolemia caused by internal hemorrhage is a major cause cations are a major cause of prolonged length of stay and death in hospitals [29, 18]. of death in critical care patients. However, hypovolemia is 2 difficult to diagnose in a timely fashion, as obvious symp- After 15-30% of total blood volume is lost [10], the pa- toms do not manifest until patients are already nearing a tient is at high risk of experiencing hypovolemic shock. Shock critical state of shock. Novel non-invasive methods for de- occurs when the heart can no longer pump enough blood to tecting hypovolemia in the literature utilize the photoplethys- the body; blood pressure plummets, and tissue perfusion mogram (PPG) waveform generated by the pulse-oximeter is not capable of sustaining aerobic metabolism, leading to attached to a finger or ear. Until now, PPG-based alarms widespread ischemic tissue damage [12]. Hypovolemic shock have been evaluated only on healthy patients under ideal can rapidly be fatal, and is a complication that arises often testing scenarios (e.g., motionless patients); however, the in at-risk patients [18]. PPG is sensitive to patient health and significant artifacts Unfortunately, assessment of decreasing volume status is manifest when patients move. Since patient health varies one of the most difficult tasks in clinical medicine [15]. At within the intensive care unit (ICU) and ICU patients typi- the onset of hypovolemia, a patient's body will attempt to cally do not remain motionless, this work introduces a PPG- compensate by increasing heart rate (to continue to deliver based monitor designed to be robust to waveform artifacts oxygen to the extremities with the diminished amount of and health variability in the underlying patient population. blood). However, heart rate alone is not sufficient to deter- To demonstrate the promise of our approach, we evaluate mine the need for emergent interventions [4], as it is aspe- the proposed monitor on a small sample of intensive care cific. Respiratory rate may rise [12], but this is often a late patients from the Physionet database. The monitor detects change [8], and can be masked by mechanical ventilation. hypovolemia within a twelve hour window of nurse docu- Blood vessels in the periphery constrict, which decreases mentation of hypovolemia when it is present, and achieves a perfusion in the extremities [32], causing subtle changes in low false alarm rate over patients without documented hy- patient visage, such as paleness, long capilary refill times, or povolemia. poor skin turgor. However, these changes are easy for clin- icians to overlook, and no definitive studies on the predic- tive ability or pathogenisis of these signs seem to exist [16]. Categories and Subject Descriptors Thus, the body's hemodynamic compensation mechanisms G.3 [Probability and Statistics]: Time series analysis; can mask underlying deterioration the patient is experienc- J.3 [Life and Medical Sciences]: Medical Information ing. Systems Fluid management is an important part of patient man- agement in critical care, in part to mitigate the risk of hy- povolemia [11]. Patient fluid inputs and outputs are closely 1. INTRODUCTION monitored for changes [2], as common medical practice holds Patients who present to emergency rooms with trauma, that these changes may reflect changes in blood volume. patients undergoing surgery, and post-operative patients in These changes only occur, however, after significant blood is intensive care units frequently experience hemorrhage. Per- lost [28]. Blood pressure is obfuscated by numerous bodily sistent internal hemorrhage can, over time, cause a decrease in the volume of blood in the circulatory system, a condi- external bleeding. However, both of these causes are much tion known as hypovolemia [12]. 1 Hypovolemia is common more apparent to clinicians when they occur, and rarely go undiscovered. Thus, we do not focus on these cases. ∗This research was supported in part by NSF CNS-1035715. 2The percentage varies with the patient's physiological com- Copyright retained by the authors pensatory mechanisms; healthier patients are more readily 1Hypovolemia can also be caused by loss of body fluids, or by able to compensate for loss in blood volume. compensatory mechanisms as well as anesthetics and other blood loss [28]. medication, which makes monitoring blood pressure unsuit- Many changes commonly taken as signs of hypovolemia able for ascertaining if the patient's blood volume is chang- have been shown to be aspecific. Decrease in systolic blood ing [7]. Change in heart rate is often subtle and, depend- pressure is aspecific over small quantities of lost blood, and ing on the size of the bleed, the change may present over there are insufficient studies to calculate its effectiveness at a number of hours. Periodic monitoring of heart rate may predicting higher volumes of blood loss. Non-severe dizzi- not capture this trend, and there are numerous confounding ness is also poorly sensitive [16]. Most other signs (skin etiologies for tachycardia [4, 7]. turgor, capillary refill, supine tachycardia) have no proven Detection is made still more challenging by inter-patient individual diagnostic role [28]. These papers also make the variability. Blood volume varies from patient to patient, important point that patients with dehydration show similar and the way the body responds to blood loss from inter- operating characteristics to those with fixed-volume blood nal bleeding varies based on the severity and location of the loss [16, 28, 12]. The optimal method of resuscitation has bleed.
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