Decision Support System Helps Guide Fluid Resuscitation

by U.S. Medicine

December 14, 2010

Washington, DC—Researchers at the US Army Institute of Surgical Research (USAISR) and the University of Texas Medical Branch (UTMB) at Galveston, TX, have developed a new system to help providers better resuscitate burn patients with large burns.

USM_12-10-BRDSS.jpgThe Burn Resuscitation Decision Support System (BRDSS) is designed to help assist acute care providers by providing them with fluid resuscitation rate recommendations for patients with large burns during the initial 48 hours after the burn.

Jose Salinas, PhD, co-inventor and task area manager for Combat Critical Care Engineering at the USAISR, explained that the development of this tool is part of an Army initiative to bring automation technology and decision support assistance to the critical care environment. “We have been doing research on different algorithms and different computer technology that can be used in the critical care environment to help automate and provide tools to providers taking care of patients.”

The burn resuscitation decision support system technology has been used at the USAISR burn center and UTMB over the last couple years as a decision support tool. It has been licensed to UTMB, which will seek FDA approval of the system. “They in turn are going to commercialize it with full FDA approval to be able to be sold to other burn centers and non-burn centers throughout the country and DoD.”

Providing a System to Help Providers

Of the returning war casualties who have burn injuries, about 20% require an acute fluid resuscitation, Salinas explained. “Normally what happens is if you get burned over 20% of your body the standard of care calls for an active fluid resuscitation.”

Administering the optimal level of resuscitation fluid to burn patients can be complex. Too much fluid can lead to abdominal compartment syndrome, which may lead to morbidity or even death. On the other hand, too little fluid could result in organ failure or death.

Currently, there are different formulas used to help providers determine the appropriate levels of fluid that should be given to the patient after the injury, Salinas explained. “The way it normally works is you start giving patients fluids at some particular rate and there are different formulas for that. You then check the patient’s urinary output. If it is too high, you turn the volume down and if it is too low you turn the volume up every hour. Even with that approach, there are still lots of cases of over resuscitation and under resuscitation because it is a fairly manually intensive process.”

Salinas said that the researchers sought to use information technology to aid clinicians as they make decisions for their patients. The system works by allowing the clinician to enter the patient’s urinary output and current fluid rates into it. The system then calculates and recommends the most appropriate fluid rate that should be given to the patient for the next hour. For the next 24 to 48 hours the system can be used to adjust the fluid rate until the patient is stable.

The clinician can determine whether to accept or decline the recommendations, according to Salinas. “If the clinician declines the recommendation, then [the clinician] has to document why he or she declines the recommendation.”

Providing Fluid Resuscitation

Salinas said the system is simple to use. If a clinician determines that the patient is burned over more than 20% of their body, then the system is turned on for the patient. “A nurse will fire up the system. It is basically a computer application. The system will ask a set of initial questions … based on that, it gives you an initial fluid rate, which is the rate that you need to start at for that patient.”

A clinician will input the necessary information into the system every hour and the system will make a fluid rate recommendation for the provider. If the provider decides to accept the recommendation, the provider simply clicks ‘okay’ on the application. “Then the application goes to sleep for one more hour and the fluid is set to the new rate.”

Preliminary studies done of the system’s use at USAISR and UTMB have found that it has kept patients on target with the appropriate fluid rate a larger percentage of the time than those who did not use the system.

Using the System in Theater

The BRDSS cannot be deployed to other centers until it gains FDA approval, Salinas explained. In addition to helping clinicians experienced with burn patients, the system will also be helpful to those with less experience with burn resuscitation once it is approved by FDA. “If we can deploy this to non-burn institutes they can use this as an additional tool to help guide resuscitation because normally they don’t have that expertise there.”

In addition, Salinas said that the resuscitation software will be integrated into a tablet PC for theater deployment to guide clinicians there. “Our hope is to push the system out to the combat support hospital, so when a patient arrives that is burned [and] needs active resuscitation they can use our system to accomplish that … So a patient comes into the combat support hospital, you grab one of the resuscitation tablets, you start the resuscitation of the patient. The tablet basically moves with the patient until they arrive here in the USAISR 72 hours later.”

Salinas hopes that more products will be developed like this system to help providers. “With all of the advancements that we have had in computer science, the impact of computers in medicine has been minimal, truly minimal. When you look at computer and information systems in medicine we are still in the stone age. So our goal is to try to move information technology in medicine to the modern world.”

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