Common alarm-related events leading to injuries or deaths.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"5202",leadTitle:null,fullTitle:"Extracorporeal Membrane Oxygenation - Advances in Therapy",title:"Extracorporeal Membrane Oxygenation",subtitle:"Advances in Therapy",reviewType:"peer-reviewed",abstract:"Extracorporeal membrane oxygenation (ECMO), despite a long and troubled history, is very rapidly evolving into a therapy that can be safely and effectively applied across the world in patients experiencing acute cardiac and/or pulmonary failure. As experiences grow, there is a better understanding of nuances of the importance of teamwork, therapy guidelines and protocols, patient selection, and understanding the functional aspects of pump-circuit technology as it interfaces with human biology. The challenges in managing these very sick and complex patients cannot be understated. The goal of this text is to provide a framework for the development and successful growth of a program. Authors from Centers of Excellence Worldwide have shared their experiences in the full spectrum in dealing with this evolving field.",isbn:"978-953-51-2553-2",printIsbn:"978-953-51-2552-5",pdfIsbn:"978-953-51-7299-4",doi:"10.5772/61536",price:139,priceEur:155,priceUsd:179,slug:"extracorporeal-membrane-oxygenation-advances-in-therapy",numberOfPages:394,isOpenForSubmission:!1,isInWos:1,isInBkci:!1,hash:"f7c8f9c0cf1cf50455fba7e2607e9268",bookSignature:"Michael S. Firstenberg",publishedDate:"September 14th 2016",coverURL:"https://cdn.intechopen.com/books/images_new/5202.jpg",numberOfDownloads:58095,numberOfWosCitations:37,numberOfCrossrefCitations:39,numberOfCrossrefCitationsByBook:2,numberOfDimensionsCitations:66,numberOfDimensionsCitationsByBook:2,hasAltmetrics:1,numberOfTotalCitations:142,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 19th 2015",dateEndSecondStepPublish:"November 9th 2015",dateEndThirdStepPublish:"February 13th 2016",dateEndFourthStepPublish:"May 13th 2016",dateEndFifthStepPublish:"June 12th 2016",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"64343",title:"Dr.",name:"Michael S.",middleName:null,surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/64343/images/system/64343.png",biography:"Dr. Michael S. Firstenberg is a thoracic surgeon at the St. Elizabeth Medical Center (Ascension), Appleton, Wisconsin. He attended Case Western Reserve University Medical School, Cleveland, OH, received his general surgery training at University Hospitals in Cleveland, and completed thoracic surgery fellowships at The Ohio State University and the Cleveland Clinic. He is an active member of the Society of Thoracic Surgeons (STS), American Association of Thoracic Surgeons (AATS), American College of Cardiology (ACC), and American College of Academic International Medicine (ACAIM), for which he served as president in 2021–2022. He has authored more than 250 peer-reviewed manuscripts, abstracts, and book chapters and has edited several textbooks and lectured worldwide on topics ranging from medical leadership, COVID-19, endocarditis, and extra-corporeal membrane oxygenation (ECMO).",institutionString:"St. Elizabeth Medical Center",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"25",totalChapterViews:"0",totalEditedBooks:"12",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1009",title:"Pre-Hospital Emergency Medicine",slug:"emergency-medicine-pre-hospital-emergency-medicine"}],chapters:[{id:"51274",title:"Introductory Chapter: Evolution of ECMO from Salvage to Mainstream Supportive and Resuscitative Therapy",doi:"10.5772/64345",slug:"introductory-chapter-evolution-of-ecmo-from-salvage-to-mainstream-supportive-and-resuscitative-thera",totalDownloads:2567,totalCrossrefCites:5,totalDimensionsCites:5,hasAltmetrics:0,abstract:null,signatures:"Michael S. Firstenberg",downloadPdfUrl:"/chapter/pdf-download/51274",previewPdfUrl:"/chapter/pdf-preview/51274",authors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],corrections:null},{id:"50706",title:"Simulation Training on Extracorporeal Membrane Oxygenation",doi:"10.5772/63086",slug:"simulation-training-on-extracorporeal-membrane-oxygenation",totalDownloads:3408,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:1,abstract:"Conventional extracorporeal membrane oxygenation (ECMO) training usually only consists of didactic lectures and water drill of ECMO circuit. However, learners cannot “experience” changes of clinical condition of patients. Simulation-based learning is a perfect answer to this by providing participantsauthentic, interactive, team-based training without risk to real patients. Hospital Authority (HA) of Hong Kong has implemented a corporatewide ECMO simulation-based training program since 2014. It aims to provide a structural and standardized training opportunity for clinical staff members to gain hands-on experience in ECMO circuit management and troubleshooting technique. In the program, participants will go through three categories of scenarios: (1) replicate common real patient clinical experience; (2) replicate incident that only happens infrequently; and (3) imitate clinical situation that is rarely happened but life threatening, and where prompt and correct actions are necessary. Every scenario has its own debriefing session that covers technical and human factor issues.Since 2014, 32 identical full-day courses were conducted and 285 doctors and nurses were trained. All participants were satisfied with the training and expressed that the simulation was an effective model for ECMO training. The training met their need and they could apply what they learned in real-life practice.",signatures:"George Wing Yiu Ng, Eric Hang Kwong So and Lap Yin Ho",downloadPdfUrl:"/chapter/pdf-download/50706",previewPdfUrl:"/chapter/pdf-preview/50706",authors:[{id:"179715",title:"Dr.",name:"Wing Yiu",surname:"Ng",slug:"wing-yiu-ng",fullName:"Wing Yiu Ng"}],corrections:null},{id:"51450",title:"ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring",doi:"10.5772/63888",slug:"ecmo-biocompatibility-surface-coatings-anticoagulation-and-coagulation-monitoring",totalDownloads:4402,totalCrossrefCites:9,totalDimensionsCites:17,hasAltmetrics:0,abstract:"The interaction between the patient and the ECMO (extracorporeal membrane oxygenation) circuit initiates a significant coagulation and inflammatory response due to the large surface area of foreign material contained within the circuit. This response can be blunted with the appropriate mix of biocompatible materials and anticoagulation therapy. The use of anticoagulants, in turn, requires appropriate laboratory testing to determine whether the patient is appropriately anticoagulated. Physicians must balance the risks of bleeding with the risks of thrombosis; the proper interpretation of these tests is often shrouded in mystery. It is the purpose of this chapter to help demystify the coagulation system, anticoagulants, biocompatible surfaces, and coagulation testing so that ECMO practitioners can make informed decisions about their patients and to spur coordinated efforts for future research to improve our understanding of these complex processes.",signatures:"Timothy M. Maul, M Patricia Massicotte and Peter D. Wearden",downloadPdfUrl:"/chapter/pdf-download/51450",previewPdfUrl:"/chapter/pdf-preview/51450",authors:[{id:"182691",title:"Dr.",name:"Timothy",surname:"Maul",slug:"timothy-maul",fullName:"Timothy Maul"},{id:"187110",title:"Dr.",name:"Peter",surname:"Wearden",slug:"peter-wearden",fullName:"Peter Wearden"},{id:"187112",title:"Dr.",name:"Patti",surname:"Massicotte",slug:"patti-massicotte",fullName:"Patti Massicotte"}],corrections:null},{id:"51795",title:"ECMO Cannulation Techniques",doi:"10.5772/64338",slug:"ecmo-cannulation-techniques",totalDownloads:4292,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"An extracorporeal membrane oxygenation (ECMO) circuit consists of a pump and a membrane oxygenator. This circuit can interface with the human body in a variety of cannulation strategies to provide different forms and levels of support. These various support techniques can be divided into two broad categories: those designed to support the body’s respiratory functions (lungs) and those designed to support the body’s blood circulation (heart). In this chapter we discuss various cannulation techniques used.",signatures:"Chand Ramaiah and Ashok Babu",downloadPdfUrl:"/chapter/pdf-download/51795",previewPdfUrl:"/chapter/pdf-preview/51795",authors:[{id:"183646",title:"Dr.",name:"Chand",surname:"Ramaiah",slug:"chand-ramaiah",fullName:"Chand Ramaiah"},{id:"189073",title:"Dr.",name:"Ashok",surname:"Babu",slug:"ashok-babu",fullName:"Ashok Babu"}],corrections:null},{id:"51211",title:"Triple Cannulation ECMO",doi:"10.5772/63392",slug:"triple-cannulation-ecmo",totalDownloads:4769,totalCrossrefCites:3,totalDimensionsCites:8,hasAltmetrics:1,abstract:"Extracorporeal membrane oxygenation (ECMO) has emerged as an invaluable tool for bridging severe isolated or combined failure of lung and heart. Due to massive technical improvements, the application of ECMO is growing fast. While historically ECMO was initiated and maintained by cardiac surgeons, in recent times interventional cardiologists and intensive care specialists increasingly run ECMO systems independently with great success. Percutaneous ECMO circuits are usually set up in a dual cannulation mode, either as veno-venous or as veno-arterial configuration. A novel advanced strategy is the cannulation of three large vessels (triple cannulation), resulting in veno-veno-arterial or veno-arterio-venous cannulation. Both veno-venous and veno-arterio-venous cannulation may further be upgraded to veno-pulmonary-arterial or veno-arterial-pulmonary arterial cannulation, respectively. Triple cannulation expands the field of ECMO application but substantially increases the complexity of ECMO circuits. In this chapter, we review percutaneous dual and triple cannulation strategies, featuring a recently proposed unifying nomenclature. This unequivocal code universally applies to both dual and triple cannulation strategies (VV, VPa, VA, VVA, VAV, VAPa). The technical evolution of ECMO is growing fast, but it has to be noted that current knowledge of ECMO support is mainly based on observation. Thus controlled trials are urgently needed to prospectively evaluate different ECMO modes.",signatures:"L. Christian Napp and Johann Bauersachs",downloadPdfUrl:"/chapter/pdf-download/51211",previewPdfUrl:"/chapter/pdf-preview/51211",authors:[{id:"180959",title:"Dr.",name:"L. Christian",surname:"Napp",slug:"l.-christian-napp",fullName:"L. Christian Napp"},{id:"181634",title:"Prof.",name:"Johann",surname:"Bauersachs",slug:"johann-bauersachs",fullName:"Johann Bauersachs"}],corrections:null},{id:"51400",title:"Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock and Cardiac Arrest",doi:"10.5772/63578",slug:"venoarterial-extracorporeal-membrane-oxygenation-in-refractory-cardiogenic-shock-and-cardiac-arrest",totalDownloads:2981,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The aim of this chapter is to discuss the indication and the role of a venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the refractory cardiogenic shock and cardiac arrest.",signatures:"Marie-Eve Brunner, Carlo Banfi and Raphaël Giraud",downloadPdfUrl:"/chapter/pdf-download/51400",previewPdfUrl:"/chapter/pdf-preview/51400",authors:[{id:"180243",title:"Dr.",name:"Marie-Eve",surname:"Brunner",slug:"marie-eve-brunner",fullName:"Marie-Eve Brunner"},{id:"181517",title:"Dr.",name:"Raphael",surname:"Giraud",slug:"raphael-giraud",fullName:"Raphael Giraud"},{id:"186328",title:"Dr.",name:"Carlo",surname:"Banfi",slug:"carlo-banfi",fullName:"Carlo Banfi"}],corrections:null},{id:"50541",title:"Extracorporeal Membrane Oxygenation Support for Complex Percutaneous Coronary Interventions in Patients without Cardiogenic Shock",doi:"10.5772/63089",slug:"extracorporeal-membrane-oxygenation-support-for-complex-percutaneous-coronary-interventions-in-patie",totalDownloads:2564,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"It has been shown that extracorporeal membrane oxygenation (ECMO) may provide cardiopulmonary support during percutaneous coronary interventions (PCI) in patients with refractory cardiogenic shock. Current guidelines consider ECMO and implantable left ventricular assist devices in selected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients. High-risk PCI remains a viable revascularization strategy for those patients who are not suitable for surgery or those refusing it. However, such a subset of patients is considered to be at an extremely high risk of PCI complications as there is a risk of hemodynamic collapse during balloon inflations or complex procedures, particularly, if coronary dissection with vessel closure or no reflow occurs. This chapter is devoted to the use of ECMO support for high-risk complex PCI in NSTE-ACS patients without cardiogenic shock based on the theoretical rationale, observational retrospective single-center studies and clinical case examples.",signatures:"Vladimir I. Ganyukov, Roman S. Tarasov and Dmitry L. Shukevich",downloadPdfUrl:"/chapter/pdf-download/50541",previewPdfUrl:"/chapter/pdf-preview/50541",authors:[{id:"180934",title:"Dr.",name:"Vladimir",surname:"Ganyukov",slug:"vladimir-ganyukov",fullName:"Vladimir Ganyukov"},{id:"181174",title:"Dr.",name:"Roman",surname:"Tarasov",slug:"roman-tarasov",fullName:"Roman Tarasov"},{id:"185318",title:"Dr.",name:"Dmitry",surname:"Shukevich",slug:"dmitry-shukevich",fullName:"Dmitry Shukevich"}],corrections:null},{id:"51029",title:"Cardiac Catheterisation and Intervention on ECMO",doi:"10.5772/63978",slug:"cardiac-catheterisation-and-intervention-on-ecmo",totalDownloads:2785,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Cardiac catheterisation is an essential tool to evaluate patients who require ECMO support for severe haemodynamic impairment. In the first part of this chapter, we describe the equipment, teamwork, expertise, techniques and precautions that are necessary to carry out safe and effective cardiac catheterisation on ECMO. We have moved on from an early pioneering era to a stage where the multidisciplinary team approach has been worked out in detail, using operational procedures that deal with the technical challenges and minimise the risks of ECMO catheterisation and intervention. In the second part of the chapter, we explain in detail how cardiac catheterisation and intervention on ECMO contribute to the management of (1) post-operative congenital heart disease patients, (2) cardiac patients who suffer sudden haemodynamic deterioration, (3) patients with low cardiac output who require left heart decompression because of extracorporeal support, (4) patients with haemodynamically unstable arrhythmias and (5) haemodynamically unstable patients who require percutaneous coronary intervention. We also provide state-of-the-art information on the elective use of ECMO to support congenital and structural catheter interventions. Acute survival and long-term outcome are now related to the underlying conditions rather than complications of the catheterisation procedure itself.",signatures:"Christopher Duke, Chris J. Harvey, Vikram Kudumula, Elved B.\nRoberts and Suhair O. Shebani",downloadPdfUrl:"/chapter/pdf-download/51029",previewPdfUrl:"/chapter/pdf-preview/51029",authors:[{id:"180294",title:"Dr.",name:"Christopher",surname:"Duke",slug:"christopher-duke",fullName:"Christopher Duke"},{id:"189238",title:"Dr.",name:"Chris",surname:"Harvey",slug:"chris-harvey",fullName:"Chris Harvey"},{id:"189239",title:"Dr.",name:"Vikram",surname:"Kudumula",slug:"vikram-kudumula",fullName:"Vikram Kudumula"},{id:"189240",title:"Dr.",name:"Elved",surname:"Roberts",slug:"elved-roberts",fullName:"Elved Roberts"},{id:"189241",title:"Dr.",name:"Suhair",surname:"Shebani",slug:"suhair-shebani",fullName:"Suhair Shebani"}],corrections:null},{id:"51267",title:"Extracorporeal Membrane Oxygenation During Lung Transplantation",doi:"10.5772/63429",slug:"extracorporeal-membrane-oxygenation-during-lung-transplantation",totalDownloads:2457,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Lung transplantation is increasing as a widely accepted surgical treatment for certain type of end-stage lung disease. Recent technical improvements in extracorporeal membrane oxygenation (ECMO) have been able to expand the role of ECMO during lung transplantation. The evolution of oxygenators, introduction of the new-type pump and tube, and improvement of percutaneous cannulation including dual lumen single catheter resulted in the technical renaissance of ECMO for lung transplantation. Now, beyond the traditional support for patients with severe primary graft dysfunction, ECMO can be established as essential perioperative roles for patients undergoing lung transplantation, such as preoperative lung protective support as a bridge to transplantation, replacement cardiopulmonary bypass during intraoperative support, and rescue of various life-threatening situations after post-transplant. After all, ECMO will be a fundamental, life-saving modality for patients during lung transplantation.",signatures:"Young-Jae Cho",downloadPdfUrl:"/chapter/pdf-download/51267",previewPdfUrl:"/chapter/pdf-preview/51267",authors:[{id:"179691",title:"Dr.",name:"Young-Jae",surname:"Cho",slug:"young-jae-cho",fullName:"Young-Jae Cho"}],corrections:null},{id:"51050",title:"Extracorporeal Membrane Oxygenation Support as Treatment for Early Graft Failure After Heart Transplantation",doi:"10.5772/64040",slug:"extracorporeal-membrane-oxygenation-support-as-treatment-for-early-graft-failure-after-heart-transpl",totalDownloads:2301,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx) accounting for >40% of deaths within 30 days postoperatively. According to the last International Society for Heart and Lung Transplantation (ISHLT) consensus statement, the graft dysfunction (GD) is to be classified into primary (PGD), in case of an unknown triggering factor or secondary (SGD) where there is a discernible cause such as acute rejection, pulmonary hypertension, or known surgical complications. The diagnosis of GD is to be made within 24 h after completion of Htx surgery and a severity scale for GD should include mild, moderate, or severe grades based on specified criteria. Mechanical circulatory support (MCS) for GD should be considered when medical management is not sufficient to support the newly transplanted graft. Currently, extra‐corporeal membrane oxygenation (ECMO) is widely accepted as treatment of severe EGF, given its easy and quick setup, the system versatility, the optimal end‐organ perfusion provided, and the possibility of both biventricular and lung assistance by usage of a low‐cost single pump.",signatures:"Antonio Loforte, Giacomo Murana, Mariano Cefarelli, Jacopo\nAlfonsi, Giuliano Jafrancesco, Francesco Grigioni, Lucio Careddu,\nEmanuela Angeli, Gaetano Gargiulo and Giuseppe Marinelli",downloadPdfUrl:"/chapter/pdf-download/51050",previewPdfUrl:"/chapter/pdf-preview/51050",authors:[{id:"42172",title:"Dr.",name:"Antonio",surname:"Loforte",slug:"antonio-loforte",fullName:"Antonio Loforte"}],corrections:null},{id:"50726",title:"Extracorporeal Membrane Oxygenation in Traumatic Injury: An Overview of Utility and Indications",doi:"10.5772/63434",slug:"extracorporeal-membrane-oxygenation-in-traumatic-injury-an-overview-of-utility-and-indications",totalDownloads:2478,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Severe respiratory failure may develop in the trauma patient as a consequence of direct lung injury, in response to trauma‐associated systemic inflammatory response syndrome (SIRS), as a result of infection, or at times as an unintended consequence of the life‐saving management of the acute traumatic injury. Approximately 0.5% of all adult trauma patients develop some form of pulmonary dysfunction along the acute lung injury (ALI) – acute respiratory distress (ARDS) spectrum, with the incidence of severe respiratory failure reaching 10–20% in multisystem trauma victims. Of concern, mortality in patients with acute respiratory failure who go on to develop severe pulmonary dysfunction can be as high as 37–50% with the use of conventional therapeutic modalities. Extracorporeal membrane oxygenation (ECMO) has been proposed as a rescue strategy when less invasive primary or adjunctive attempts fail. Numerous case reports and single‐center studies demonstrate potential benefits of early implementation of veno‐venous (VV)‐ECMO for the treatment of severe respiratory failure associated with trauma or sequelae of trauma. In this clinical context, VV‐ECMO can be employed to correct for both ventilatory and oxygenation failure while allowing the treating physician to provide much needed rest to the patient's lungs and permit healing to take place. The use of ECMO (mainly veno‐venous, with limited use of veno‐arterial circuits for cardiac indications) has been described in patients with severe chest injuries, traumatic pneumonectomy, bronchopleural fistulas, and various forms of respiratory failure refractory to conventional therapies.",signatures:"Ronson Hughes, James Cipolla, Peter G. Thomas and Stanislaw P.\nStawicki",downloadPdfUrl:"/chapter/pdf-download/50726",previewPdfUrl:"/chapter/pdf-preview/50726",authors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"},{id:"183810",title:"Dr.",name:"Ronson",surname:"Hughes",slug:"ronson-hughes",fullName:"Ronson Hughes"},{id:"187661",title:"Dr.",name:"James",surname:"Cipolla",slug:"james-cipolla",fullName:"James Cipolla"},{id:"187662",title:"Dr.",name:"Peter",surname:"Thomas",slug:"peter-thomas",fullName:"Peter Thomas"}],corrections:null},{id:"50732",title:"Anesthetic Management of Patients on ECMO",doi:"10.5772/63309",slug:"anesthetic-management-of-patients-on-ecmo",totalDownloads:4529,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"The management of a patient placed on extracorporeal membrane oxygenation (ECMO) is a team effort. The anesthesiology team plays an integral part during cannulation and oftentimes as well during decannulation. In addition, the management of a patient taken to the operating room on ECMO requires a degree of expertise. This chapter will review monitors, echocardiography, medications, fluid and blood management protocols, and ventilation strategies to help the anesthesiology team provide best care for this patient population.",signatures:"Mark A. Taylor and Yasdet Maldonado",downloadPdfUrl:"/chapter/pdf-download/50732",previewPdfUrl:"/chapter/pdf-preview/50732",authors:[{id:"180258",title:"Dr.",name:"Yasdet",surname:"Maldonado",slug:"yasdet-maldonado",fullName:"Yasdet Maldonado"},{id:"181532",title:"Dr.",name:"Mark",surname:"Taylor",slug:"mark-taylor",fullName:"Mark Taylor"}],corrections:null},{id:"51352",title:"Management of Mechanical Ventilation During Extracorporeal Membrane Oxygenation",doi:"10.5772/64248",slug:"management-of-mechanical-ventilation-during-extracorporeal-membrane-oxygenation",totalDownloads:2980,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:1,abstract:"This chapter explores the best practices of mechanical ventilation during extracorporeal membrane oxygenation (ECMO) through a detailed discussion of the physiologic theory and clinical evidence. Future areas of study and unanswered questions about mechanical ventilation during ECMO are also delineated.",signatures:"David Stahl and Victor Davila",downloadPdfUrl:"/chapter/pdf-download/51352",previewPdfUrl:"/chapter/pdf-preview/51352",authors:[{id:"183258",title:"Dr.",name:"Victor",surname:"Davila",slug:"victor-davila",fullName:"Victor Davila"},{id:"183318",title:"Dr.",name:"David",surname:"Stahl",slug:"david-stahl",fullName:"David Stahl"}],corrections:null},{id:"51673",title:"Sedation, Analgesia Delirium in the ECMO Patient",doi:"10.5772/64249",slug:"sedation-analgesia-delirium-in-the-ecmo-patient",totalDownloads:3285,totalCrossrefCites:3,totalDimensionsCites:4,hasAltmetrics:0,abstract:"The goal of this chapter is to identify medications frequently utilized for sedation and analgesia in Extracorporeal Membrane Oxygenation (ECMO) patients. In addition to describing basic pharmacologic principles of these medications, we discuss their benefits and disadvantages and explain the effects the ECMO circuitry will have on pharmacokinetics of each drug. We also discuss need for various depths of sedation and the utility of neuromuscular blocking agents. Emerging techniques for achieving appropriate sedation will be identified. An explosion of literature in recent years has led to Intensive Care Unit (ICU) delirium increasingly being recognized as an indicator of poor outcomes in the general ICU population. We discuss strategies to manage this complex and multifactorial issues, and how they can be applied to our particular subpopulation of ECMO patients.",signatures:"SV Satyapriya, ML Lyaker, AJ Rozycki and Papadimos",downloadPdfUrl:"/chapter/pdf-download/51673",previewPdfUrl:"/chapter/pdf-preview/51673",authors:[{id:"183288",title:"Dr.",name:"S. Veena",surname:"Satyapriya",slug:"s.-veena-satyapriya",fullName:"S. Veena Satyapriya"}],corrections:null},{id:"51568",title:"Weaning Strategy from Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO)",doi:"10.5772/64013",slug:"weaning-strategy-from-veno-arterial-extracorporeal-membrane-oxygenation-ecmo-",totalDownloads:4030,totalCrossrefCites:2,totalDimensionsCites:6,hasAltmetrics:0,abstract:"Background: Significant advances in extracorporeal technology have led to the more widespread use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiac failure. However, procedures for weaning from VA ECMO are not standardized. High death rate after successful weaning shows that many questions remain unresolved in this field.",signatures:"Nadia Aissaoui, Christoph Brehm, Aly El-Banayosy and Alain\nCombes",downloadPdfUrl:"/chapter/pdf-download/51568",previewPdfUrl:"/chapter/pdf-preview/51568",authors:[{id:"180317",title:"Dr.",name:"Nadia",surname:"Aissaoui",slug:"nadia-aissaoui",fullName:"Nadia Aissaoui"}],corrections:null},{id:"51612",title:"Neurologic Issues in Patients Receiving Extracorporeal Membrane Oxygenation Support",doi:"10.5772/64269",slug:"neurologic-issues-in-patients-receiving-extracorporeal-membrane-oxygenation-support",totalDownloads:2716,totalCrossrefCites:3,totalDimensionsCites:4,hasAltmetrics:0,abstract:"Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for patients experiencing acute severe cardiac and/or respiratory failure. Unfortunately, despite noteworthy improvements in patient selection, technology, and multidisciplinary team management, significant complications are still common. The most dramatic and potentially severe complications are neurologic. However, the incidence of neurologic complications (i.e. embolic stroke, intracerebral hemorrhage, seizures, and anoxic injuries) has not been completely defined. Unfortunately, brain death and neurologic injuries are significant causes of morbidity and mortality for patients requiring an ECMO support. Critical to the management of patients requiring ECMO is a broader understanding of neurologic monitoring along with the clinical assessment and management of neurologic events. It is important to evaluate and potentially intervene early in the event of a neurologic problem to minimize its clinical significance. Hopefully, with a better understanding of the pathophysiology, diagnostic and therapeutic tools, and prevention strategies, the true incidence of neurologic complications can be understood and minimized.",signatures:"Susana M. Bowling, Joao Gomes and Michael S. Firstenberg",downloadPdfUrl:"/chapter/pdf-download/51612",previewPdfUrl:"/chapter/pdf-preview/51612",authors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"},{id:"183813",title:"Associate Prof.",name:"Dr. Susana",surname:"Bowling",slug:"dr.-susana-bowling",fullName:"Dr. Susana Bowling"},{id:"183815",title:"Dr.",name:"Joao",surname:"Gomes",slug:"joao-gomes",fullName:"Joao Gomes"}],corrections:null},{id:"51344",title:"Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy",doi:"10.5772/64164",slug:"extracorporeal-membrane-oxygenation-and-continuous-renal-replacement-therapy",totalDownloads:2942,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Extracorporeal membrane oxygenation (ECMO) is a supportive therapy, which provides cardiopulmonary and end-organ support in critically ill patients when other measures fail. These patients receive large amounts of fluid for volume resuscitation, blood products and caloric intake, which results in fluid overload and which in turn is associated with impairment of oxygen transport and increased incidence of multiple organ failure especially heart, lungs and brain. It is common to see a decrease in urine output during ECMO that may be associated with acute renal failure. The acute renal failure is a manifestation of multiple organ system failure due to acute decompensated heart failure, sepsis, hemolysis, use of vasopressors/inotropes, nephrotoxic medications, and activation of complement system during ECMO support. It is associated with poor prognosis and higher mortality in ECMO patients. Continuous renal replacement therapy (CRRT) in patients on ECMO provides an efficient and potentially beneficial method of fluid overload and acute kidney injury management. In addition, recent data suggest that the use of CRRT may remove inflammatory cytokine released as a result of circulation of blood across synthetic surfaces during ECMO. The two most common methods to provide CRRT are through the use of an inline hemofilter or through a traditional CRRT device connected to the extracorporeal circuit. The primary objective of this chapter is to discuss current state and role of renal replacement therapy in patients on ECMO and address the controversies and challenges about its application.",signatures:"Bijin Thajudeen, Sepehr Daheshpour and Babitha Bijin",downloadPdfUrl:"/chapter/pdf-download/51344",previewPdfUrl:"/chapter/pdf-preview/51344",authors:[{id:"179777",title:"Dr.",name:"Bijin",surname:"Thajudeen",slug:"bijin-thajudeen",fullName:"Bijin Thajudeen"},{id:"179778",title:"Dr.",name:"Babitha",surname:"Bijin",slug:"babitha-bijin",fullName:"Babitha Bijin"}],corrections:null},{id:"51329",title:"Practical and Theoretical Considerations for ECMO System Development",doi:"10.5772/64267",slug:"practical-and-theoretical-considerations-for-ecmo-system-development",totalDownloads:2610,totalCrossrefCites:4,totalDimensionsCites:4,hasAltmetrics:0,abstract:"Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for the temporary substitution for the heart and/or lungs in patients with acute cardiac or pulmonary failure. Recently, the development of portable systems has allowed for implementation of therapy outside of the intensive care units. ECMO can even be initiated in out-of-hospital situations to allow for patient stabilization and subsequent transfer to an appropriate hospital. This chapter will focus on the authors’ development of a perfusion system based on a new double chamber pump. This unique design will, in theory, allow for a more complete and effective circulatory support to allow for myocardial and pulmonary recovery. The evolution from bench-top to animal testing will be described. The theoretical issues—including the advantages and disadvantages of roller and centrifugal pump designs—will also be discussed.",signatures:"Nodar Khodeli, Zurab Chkhaidze, Jumber Partsakhashvili, Otar\nPilishvili and Dimitri Kordzaia",downloadPdfUrl:"/chapter/pdf-download/51329",previewPdfUrl:"/chapter/pdf-preview/51329",authors:[{id:"179989",title:"Dr.",name:"Dimitri",surname:"Kordzaia",slug:"dimitri-kordzaia",fullName:"Dimitri Kordzaia"},{id:"181624",title:"Prof.",name:"Nodar",surname:"Khodeli",slug:"nodar-khodeli",fullName:"Nodar Khodeli"},{id:"185407",title:"Prof.",name:"Zurab",surname:"Chkhaidze",slug:"zurab-chkhaidze",fullName:"Zurab Chkhaidze"},{id:"185408",title:"Dr.",name:"Jumber",surname:"Partsakhashvili",slug:"jumber-partsakhashvili",fullName:"Jumber Partsakhashvili"},{id:"185409",title:"Dr.",name:"Otar",surname:"Pilishvili",slug:"otar-pilishvili",fullName:"Otar Pilishvili"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6268",title:"Vignettes in Patient Safety",subtitle:"Volume 2",isOpenForSubmission:!1,hash:"0d2a1e477127a80d432276b11e6806d0",slug:"vignettes-in-patient-safety-volume-2",bookSignature:"Michael S. 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Plasma has uses in refrigeration, biotechnology, health care, microelectronics and semiconductors, nanotechnology, space and environmental sciences, and so on. This book provides a comprehensive overview of PST, including information on different types of plasma, basic interactions of plasma with organic materials, plasma-based energy devices, low-temperature plasma for complex systems, and much more.",isbn:"978-1-83969-624-4",printIsbn:"978-1-83969-623-7",pdfIsbn:"978-1-83969-625-1",doi:"10.5772/intechopen.95256",price:119,priceEur:129,priceUsd:155,slug:"plasma-science-and-technology",numberOfPages:246,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"c45670ef4b081fd9eebaf911b2b4627b",bookSignature:"Aamir Shahzad",publishedDate:"February 23rd 2022",coverURL:"https://cdn.intechopen.com/books/images_new/10921.jpg",keywords:null,numberOfDownloads:1385,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 2nd 2021",dateEndSecondStepPublish:"March 30th 2021",dateEndThirdStepPublish:"May 29th 2021",dateEndFourthStepPublish:"August 17th 2021",dateEndFifthStepPublish:"October 16th 2021",remainingDaysToSecondStep:"a year",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:"Dr. Shahzad has completed his Ph.D. and Post Doctorate from Xi’an Jiaotong University, he is involved in research that explores novel computational methods for transport behaviors of dusty plasma.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"288354",title:"Dr.",name:"Aamir",middleName:null,surname:"Shahzad",slug:"aamir-shahzad",fullName:"Aamir Shahzad",profilePictureURL:"https://mts.intechopen.com/storage/users/288354/images/system/288354.jpg",biography:"Aamir Shahzad has more than seventeen years of experience in university research and teaching both at home and abroad. He received his doctoral and postdoctoral degrees from Xi’an Jiaotong University (XJTU), China, in 2012 and 2015, respectively. His research interests include computational physics, complex fluids/plasmas, CFD, complex Fluids. Currently, Dr. Shahzad is an associate professor in the Department of Physics, the Government College University Faisalabad (GCUF), Pakistan. 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Phytophenols, also called polyphenols or simply phenols, are a unique group of monocyclic and polycyclic phytochemicals found within fruits, vegetables, and other plants as a component of plant fiber. Phytophenols are ubiquitously found as secondary metabolites in plants and are therefore consumed in relatively high quantities. They are a very diverse and multi-functional group of active plant compounds with substantial health potential in many areas, and numerous scientific studies demonstrate that increasing the intake of plant foods rich in fiber can minimize the incidence of modern diseases [1–3].
\nConsumption of foods and beverages containing phytophenols may impact nutrient levels in the body by preventing their oxidation. Their activity is based on functional groups’ capacity to accept a free radical’s negative charge [4, 5]. In order to be absorbed by intestinal epithelial cells, phytophenols attached to fiber can only be released by the enzymatic activities of the gastrointestinal (GI) microbiota [6–9] because the phenolic esterase enzymes necessary to release antioxidant phytophenols from plant fiber are not produced by the host GI system. It has been shown
All phytophenols arise from a common intermediate, phenylalanine, or a close precursor, shikimic acid [14]. Often they are present in conjugated forms, with sugar residues linked to hydroxyl groups, although in some cases, direct links of the sugar to an aromatic carbon do exist. In addition, associations with other compounds are also common, including linkages with carboxylic and organic acids, amines, and lipids, as well as associations with other phenols [15].
\nPlants produce an impressive array of phenolic compounds, and it is thought that these plant-based constituents have a stronger biological antioxidant effect when compared to synthetic antioxidants. This is mainly because phytophenols are part of the normal function of living plants and therefore are thought to have better compatibility with the body [4, 16, 17]. Although there are more than 8000 identified polyphenolic compounds, they can be sorted into four main classes: phenolic acids, flavonoids, stilbenes, and lignans [18]. Figure 1 illustrates the different groups, which are divided by the number of rings they contain as well as the structural elements that bind these rings together.
\nPhenolic acids are derivatives of either benzoic acid or cinnamic acid and can thus be divided into two classes. They make up about a third of the polyphenolic compounds found in human diets. These phenolic compounds can be found in all plant-based material, although they are most commonly found in acidic fruits [19]. Flavonoids are the most abundant polyphenolic compounds found in our diet and are also the most well-studied group. More than 4000 varieties have been accounted for, often contributing to the color of flowers, fruits, and leaves [20]. Six subclasses exist, as shown in Figure 2, based upon variations in structure: flavonols, flavones, flavanones, flavanols, anthocyanins, and isoflavones.
\nChemical structures of the different classes of polyphenols, broadly divided into four classes [
Chemical structures of subclasses of flavonoids [
Stilbenes contain two phenyl moieties connected by a two-carbon methylene bridge. Their synthesis is typically initiated as a result of injury or infection in plants, and as a consequence, their occurrence in our diet is much lower than either phenolic acids or flavonoids. The best studied stilbene is resveratrol, found mainly in grapes and as a result also in red wine. Lignans are diphenolic compounds formed by the dimerization of two cinnamic acid residues, as seen in Figure 1.
\nEstimating the total polyphenol content is most accurately done through analysis of every individual phytophenolic compound. Due to the large diversity in phytophenolics, the only way to complete this task is through a compilation of the literature data. Fortunately, the USDA database contains a nearly complete source of food composition data [21–23]. This database combined with other literature sources for the remaining phytophenolic compounds was used to develop the Phenol-Explorer database. This recently developed database is the most complete source on the content of polyphenols in foods, including glycosides, esters, and aglycones of flavonoids, phenolic acids, lignans, stilbenes, and other polyphenols [24].
\nThe occurrence of dietary phenolics in plants is not uniform, even at the cellular level. Insoluble phytophenols are often found in cells walls, while soluble phytophenols are found within the vacuoles of plant cells [25]. In many instances, plant-based foods contain a variable mixture of polyphenols. Some polyphenols, such as flavanones and isoflavones, are found only in specific foods, whereas others such as quercetin are found in nearly all plant products. Conventionally, the outer tissues of a plant contain higher levels of phenolics than the inner tissues [26].
\nVarious other factors can affect the concentration of dietary phytophenols, including ripeness of the plant when harvested, environmental factors, storage, and processing of plant materials [14]. Before harvesting, abiotic factors such as soil type, exposure to sunlight, and amount of rainfall can alter phenolic compounds in plants. In addition, the degree of ripeness when harvested can be positively or negatively correlated with the concentration of polyphenols, depending upon which compound is under observation [27]. Storage of plant-based foods also affects polyphenol levels, and the oxidation of polyphenols over time can be beneficial (as in the case of black tea) or harmful (as in the case of browning of fruit) to polyphenolic compound concentrations [27]. Cooking also has a major effect on phytophenolic compounds, and depending on how the material is processed, cooking may account for a 30–80% loss of phenolic content [28].
\nBioavailability is described as the proportion of the nutrient that follows natural pathways to be digested, absorbed, and metabolized in the body. For phytophenols, there is no relationship between the quantity of phenolic compounds found in food and their bioavailability, and every one of the numerous known polyphenols differs in its bioavailability. Furthermore, the most ubiquitous phytophenols found in plant-based foods are not necessarily the same as those that show the highest concentration of metabolites in tissues. Often, polyphenols are present in a form that cannot directly be absorbed by the body, including esters, glycosides, or polymers [29]. Due to the microbial modification of phytophenols during absorption in the intestinal cells and later in the liver, the compounds reaching the bloodstream and bodily tissues are drastically different from those originally ingested. As a consequence, identifying all the metabolites and subsequently evaluating their activity is a difficult task. It is the chemical structure of the phytophenolic compound that determines absorption rate and extent rather than the concentration of the compound found in the diet [30]. Evidence does indirectly suggest that phenols are absorbed to some extent through the gut barrier due to an increase in antioxidant capacity of plasma after ingestion of phytophenol-rich foods [31, 32].
\nThe potential pharmacological properties of these natural plant compounds have been demonstrated
ROS are the by-products of cellular redox processes in the body. These free radical compounds contain one or more unpaired electrons in their outer orbit, creating instability that leads to significant reactivity. ROS species include superoxide (O2•−), hydroxyl (•OH), peroxyl (ROO•), lipid peroxyl (LOO•), and alkoxyl (RO•) radicals. Oxygen free radicals can also be converted to other non-radical reactive species, which are dangerous for health due to their tendency to lead to free radical reactions in living organisms. These species include hydrogen peroxide (H2O2), ozone (O3), singlet oxygen (1/2O2), and hypochlorous acid (HOCl). ROS are capable of modifying structural proteins or inactivating enzymes, and as a consequence disrupting normal physiologic functions in the body [42–44]. Production of free radicals is a normal part of our physiology and occurs continually to keep the body functioning properly. Processes that generate ROS include activities of the immune system, metabolism, and inflammation responses, along with stress, pollution, radiation, diet, toxins, exhaust fumes, and smoking. [4, 16, 42, 45].
\nExcessive production of ROS can easily overwhelm both the enzymatic and non-enzymatic antioxidant defense systems, leading to oxidative stress and inflammation. It has been widely discussed in scientific literature that increasing the intake of natural antioxidants minimizes the deleterious effects of ROS [34, 46–48]. Evidence collected from feeding assays using diets rich in antioxidant plant phenolics supports this claim [2, 7, 49]. The intake of phytophenols has been shown to minimize the production of ROS and mitigate their harmful impact on the GI system [3, 33, 50].
\nOxidative stress leads to disease through four destructive pathways: membrane lipid peroxidation, protein oxidation, DNA damage, and disturbance of reducing equivalents in the cell [4]. These steps often lead to altered signaling pathways and cell destruction. Oxidative stress has been connected to various diseases such as cancer, cardiovascular diseases, neurological disorders, diabetes, and aging. Each molecule in the body is at risk of damage by ROS, and damaged molecules can impair cellular functioning and lead to cell death, which ultimately results in diseased states [43, 44, 51]. Due to the antioxidant properties of phytophenolic compounds, they are associated with the prevention of a large array of diseases, including cardiovascular disease, cancer, diabetes, rheumatoid arthritis, neurodegenerative diseases, GI diseases, renal disorders, pulmonary disorders, eye disorders, infertility, and pregnancy complications, as well as slowing the progression of aging [4].
\nAlthough reduction of ROS has been shown to decrease risk of a huge array of diseases, the classical model of ROS generation and resulting oxidative stress contrasts with some emerging scientific evidence. Benefits of ROS can in fact occur when these species are present in low/moderate concentrations, as part of normal physiological functions [43]. The majority of cells produce superoxide and hydrogen peroxide constitutively, while other cells possess inducible ROS release systems. Beneficial effects can include defense against infectious agents by phagocytosis, killing of cancer cells by macrophages and cytotoxic lymphocytes, detoxification of xenobiotics by Cytochrome P450, generation of ATP in mitochondria (energy production), cell growth, and the induction of mitogenic responses at low concentrations. ROS also plays a role in cellular signaling, including activation of several cytokines and growth factors, non-receptor tyrosine kinase activation, protein tyrosine phosphatase activation, release of calcium from intracellular stores, and activation of nuclear transcription factors. ROS can also initiate vital actions such as gene transcription and regulation of soluble guanylate cyclase activity in cells [44, 50].
\nReactive oxygen species (ROS) are known to play a dual role in biological systems; they are well documented for playing a role as both deleterious and beneficial species [43, 44, 52]. We hypothesize that redox homeostasis in the GI tract is dependent on the dynamic interplay between the generation of ROS and the ROS quencher ability of antioxidant phytophenols released by intestinal microbes. Although there are possible benefits to maintain low levels of ROS in the proper functioning of the body, the diet and lifestyle of the majority results in increased levels of ROS in the body are known to be harmful and can lead to the progression of disease. In this way, it is critical to maintain the proper balance of ROS in the body, and phenolic compounds have been shown to reestablish a healthy level of ROS. Next, we turn to the vital interaction of phytophenols and microflora of the gut system that can lead to creation of redox balance critical to health.
\nThe group known as lactobacilli is composed of several genera of bacteria (
The
The extensive use of these bacteria in food and beverage industries drove the scientific attention toward the evaluation of their impact on health, mainly on the GI system’s integrity and responsiveness. Regardless, lactic acid bacteria were safely used for centuries to modify food flavor and texture, modern genomics bring back to light the scientific discussion toward their impact on human health [54, 58].
\nStudies of the human microbiome revealed that lactobacilli could occupy different microhabitats in the human body, such as the buccal cavity and nasal fossa, but they mainly thrive in the gut and the urogenital tract [59]. In women, it was observed that variations of estrogen and glycogen stimulates the growth of lactic acid bacteria. Depletion of vaginal lactobacilli could give rise to adverse microbial flora colonization inducing urogenital infection [60]. Gustafsson
Lactobacilli are excellent organic acid producers, converting sugars into lactic acid and other by-products such as acetate, ethanol, CO2, butyrate, and succinate. They produce small molecules, as well, such as H2O2, or compounds such as diacetyl, or acetaldehyde [67]. Several of these metabolites are bioactive, with beneficial effects for the human GI. At the same time, they are essential for the dairy industry because they provide flavoring and display natural preservative properties [68]. They help to maintain the integrity of GI layers, favoring the renewal of the epithelium. A continuous renewal of the GI layers is critical to maintain an adequate barrier function to minimize several significant human diseases, including autoimmunity and cancer. According to recently published studies, the production of low amounts of H2O2 at the GI level is beneficial to the host. Besides its well-characterized antimicrobial activity, this molecule could directly down-regulate the early stages of the host inflammatory response and improve epithelial cell restitution and healing via the oxidation of cysteine residues in the host tyrosine phosphatases [62, 69].
\nOther important metabolites synthesized by
Maintenance of the GI redox homeostasis is essential in minimizing human diseases. The production of enzymes, which could increase the amount of free and active antioxidant agents in the GI lumen, is another important characteristic associated with several
The released monophenols (caffeic acid or other cinnamic acids) may exert its biological activities on the host, either at the level of the colonic mucosa itself, or in other tissues and organs, possibly after further modification by mammalian enzymes in the liver [80]. The release and solubilization of these phenolics, from fiber, also favor its absorption and further modification by other GI commensals.
The capacity of lactic acid bacteria to transform phenolic compounds into smaller novel molecules able to be absorbed in the GI system reoriented modern research to use combinations of probiotics and prebiotic products together. A large variety of dietary fibers were used for this purpose. Yet, the microbial metabolism of the released compounds by different bioconversion pathways, such as glycosylation, deglycosylation, ring cleavage, methylation, glucuronidation, and sulfate conjugation, depends on the microbial strains and substrates used. The results of such combinations are a large array of new metabolites, many of them recognized as bioactive molecules. This strategy demonstrates to have the potential to produce extracts with a high-added value from plant-based matrices (soybean, apple, cereals, among others).
\nStudies of apple juice fermentation to manage hyperglycemia, hypertension, and modulation of microbiota composition were also carried out. Apple juice, fermented by
The benefits of
The ability of lactic acid bacteria to metabolize dietary phytophenols prompts the use of new component combinations in fermented products. Several of these new blends were formulated with plant extracts rich in aromatic compounds. Example of this is the addition of green tea in bioyogurts fermented with selected lactic acid bacteria. Species such as
The intestinal epithelium is one of the most immunologically active surfaces of the body due to the high abundance of microbes and food antigens that are constantly exposed to the GI system. The mucosal surface of the intestinal epithelium is the first line of defense from invading pathogens in the GI tract. Breaching this barrier and subsequently activating aberrant immune signaling have been involved in many diseases, both locally and systematically related. In this context, it has been proposed that there is a complex interplay between gut resident microbiota [95, 96], gut permeability [97], and altered immune function in the development of type 1 diabetes [98].
\nCurrently, our scientific efforts are directed on characterizing a strain of
As it was described before, the release of antioxidant compounds by probiotic bacteria is relevant since an enhanced oxidative stress response triggered by the excessive production of reactive oxygen species is observed in T1D and other diseases [105–107]. This characteristic was relevant in the study because a low dosage of ferulic acid stimulates the release of insulin and alleviates symptoms common to T1D in rodents [83, 108, 109]. Therefore, it would seem plausible that orally administering lactic acid bacteria containing CE qualities would help reduce blood glucose levels and ultimately prevent the onset of diabetes. To confirm this, a feeding experiment of
As it was observed that an altered intestinal microbiota was associated with diabetes onset, as previously suggested [95, 96], gut permeability and barrier function were investigated next between
Among the destructive properties of reactive oxygen species (ROS) generated during early disease development is its ability to disrupt the function of epithelial tight junction proteins [113]. To determine the extent of the oxidative stress environment, ileal mucosal hexanoyl-lysine levels were quantified by ELISA and a significant increase of levels was observed in diabetic animals when compared to healthy controls and
Since it has been determined that
As more is studied about
After experiencing reduced kynurenine production and IDO inhibition in response to
Figure 4 most accurately summarizes the work our group has done in characterizing
Gastrointestinal (GI) epithelium with proposed mechanisms of phytophenol and H2O2 action. This figure summarizes the results published by the group between 2009 and 2014.
Although
This material is based upon work that is supported by the National Institute of Food and Agriculture, US Department of Agriculture, under award number 2015-67017-23182, and Juvenile Diabetes Research Foundation under award number 1-INO-2014-176-A-V.
\nHighly reliable, precise, user-friendly, and cost-effective clinical alarm systems are critical to efficient functioning of health-care facilities [1, 2, 3]. Despite tremendous progress over the past few decades, the “perfect solution” remains elusive, with focus being placed primarily on clinical indications and appropriateness of use for the existing equipment and monitoring frameworks [3, 4, 5, 6]. Beyond the concept of “false alarm,” suboptimal implementation of clinical monitoring systems can have much more profound and potentially dangerous consequences [7, 8, 9]. One such consequence, and the primary topic of this chapter, is the phenomenon of alarm fatigue (AF). It is defined as the decrease of clinician response caused by excessive alarms, sensory overload, and desensitization, in addition to other occupational and environmental variables [9, 10, 11]. Among contributing factors are also high staff workload, long shift hours, and work environments with high noise levels, all of which contribute to the “desensitization effect” associated with AF [10, 12].
\nHospital patient care units tend to be high-paced and potentially unpredictable environments, with complex workflows. Multiple simultaneous interactions between patients, families, and health-care staff may create an added element of chaos [13, 14]. To help nurses and other staff cope with their many responsibilities, various audible and visual alerts have been implemented to prompt immediate response and clinical assessment of patients [15]. These alerts are relayed from patient monitoring devices, which provide continuous flow of vital sign data with a high degree of sensitivity. The advanced technology used in these surveillance systems has provided a significant amount of physiological data at low cost while being particularly helpful by facilitating the monitoring of critically ill patients to identify deviations of vital signs (e.g., heart rate, respiratory rate, blood pressure, and pulse oximetry) from normal ranges [16]. However, when various clinical alarm systems are superimposed on the need for constant vigilance in the setting of highly challenging and often chaotic environment of the typical clinical unit, the stage is set for the emergence of AF and other forms of cognitive lapses [17, 18, 19].
\nThe prevalence of various monitoring modalities has increased significantly, with most health-care institutions utilizing some broadly defined combination of different alarm systems. As the use of these systems became more widespread, a major flaw became evident: the excessive amount of triggered alarms was contributing to unintended consequences, both in terms of patient outcomes and staff fatigue/dissatisfaction [8, 20, 21]. The high rate of nonactionable alarms, where immediate action is not required on the behalf of clinicians, was especially problematic [22]. In fact, the increasing frequency of “false alarms” has a significant desensitization effect on hospital staff, whereby some alarms may be erroneously “dismissed by assumption” as being “noncritical” [23]. This desensitization leads to both increased response times and decreased, or even lack of, clinician response. In the setting of a busy hospital, it is commonplace to hear constant chimes and beeps, each coming from different machines and indicating different “alarm conditions” (Figure 1). It should be more of an expectation that clinicians become desensitized to extraneous stimuli given the constant sensory bombardment coupled with the need for vigilance and differential interpretation of each alarm [25, 26]. When further compounded by heavy clinical workloads and long shifts, it becomes a matter of “statistical probability” before a critical alarm is missed [27, 28, 29]. Given the effect of this potentially dangerous phenomenon on both quality and safety of patient care, closer scrutiny of AF and related concepts is warranted. In this chapter, we will present a vignette-based discussion outlining fairly typical AF scenarios. Opportunities for improvement, including equipment, personnel, and systems-based considerations, will then be provided.
\nConceptual model for daily observed alarms at a typical acute care hospital. Data shown in proportion to different scales, from individual patient to entire institution, showing the true magnitude of the problem (source: Ref. [
For the purposes of this chapter, the authors performed a thorough literature search using PubMed, Google Scholar™, and Bioline International. Primary search terms included “alarm fatigue,” “health-care alarms,” “patient monitoring,” “provider burnout,” as well as secondary terms consisting of various combinations of primary search terms. From over 47,000 unique search results, we distilled 73 most pertinent references immediately relevant to this document. Finally, additional sources that were cited across our primary search results were added, for a total of 101 references included in the final manuscript.
\nA diverse number of patient monitors are widely used across various health-care settings [30, 31, 32]. When employed correctly, they provide potentially valuable, actionable, and real-time information about a patient’s clinical status. Different monitoring devices are intended to measure different parameters, potentially allowing for rapid assessment of a patient. This is especially relevant in the context of the current discussion of AF and more specifically the domain of alarm trigger accuracy [32, 33]. As clinical monitoring becomes more sophisticated and better integrated, remote (off-site) implementations also become possible [34, 35, 36]. The subsequent discussion will outline major types of monitoring equipment and alarms, including ventilation/oxygenation, hemodynamic, and pressure point alert systems.
\nIn general, primary ventilation/oxygenation alarms (VOA) include capnography and pulse oximetry, respectively. More broadly, respiratory parameter monitoring indicates the patient’s oxygen saturation, respiratory rate, and end-tidal carbon dioxide [33, 37]. The use of VOA has been particularly important for critically ill patients who require mechanical ventilatory support. In such applications, the monitor is designed to be exquisitely sensitive to detect even the slightest changes in a patient’s oxygenation or ventilation status [38]. As demonstrated in
Hemodynamic alarms (HA) monitor a variety of parameters, of which the most common ones include heart rate, systolic/diastolic/mean blood pressure, and various other intravascular pressure measurements via both invasive and noninvasive approaches [37, 40]. Hemodynamic monitoring has become a useful tool for the bedside assessment of patients in a number of clinical scenarios, from routine telemetry applications to advanced intravascular catheter utilization. There is some degree of predictability based on measured parameters, especially when trend determination and volume responsiveness are being considered [41, 42]. Hemodynamic monitors are particularly important in the setting of an unstable (or potentially unstable) patient, similar to the one described in
Bed and chair pressure sensor (BCPS) alarms are utilized across many hospitals and other health-care facilities to help reduce mechanical falls among patients who experience ambulatory or balance difficulties [47, 48]. Falls typically occur as patients attempt to mobilize and/or ambulate without the required assistance of trained health-care staff [49]. Consequently, the use of BCPS alarms serves to alert staff—typically by a pressure-sensitive mechanism—when a patient attempts to move from a bed or chair without assistance. However, the weight-sensitive pads are easily triggered by very slight patient movement, resulting in a significant number of false alarms [50, 51]. This challenge was readily apparent in
In summary, the above-referenced monitor/alarm types have become an important part of the modern health-care fabric. Despite their ubiquitous use and great potential for constructive and practical clinical application, each type of device carries inherent flaws that providers must be aware of. Detailed knowledge of the risk-benefit equation associated with each device and clinical alarm type is important not only for patient safety but also required to help improve the quality and accuracy of the next generation of monitoring devices.
\nPatient monitors are designed to have high sensitivity to predefined changes in various measured parameters, including vital signs, respiratory/ventilator status, and patient movements. However, the major drawback associated with high alarm sensitivity is the poor specificity and inherently disproportionate number of nonactionable (or nonclinical) alarms triggered [22, 53, 54]. Depending on the specific alarm and clinical setting, the estimated in range of “false positives” may be as high as 80–99% of all triggered alarms [8]. Broadly speaking, nonactionable alarms can be categorized as false alarms, nuisance alarms, and technical alarms (Figure 1). To elaborate further, false alarms occur in the absence of an actual patient or system trigger and typically result from a measurement artifact [55]. Technical alarms mandate the provider to attend to some operational aspect of the monitoring system, such as when readjustment of monitor leads/sensors is required [21]. Nuisance alarms are defined as clinically insignificant alarms that may interfere with patient care [10]. In aggregate, these nonactionable alarms are a major cause of the overall desensitization of hospital staff that may ultimately result in AF (Figure 2).
\nSchematic representation of the classification of alarm types triggered by various patient monitoring systems, including both actionable and nonactionable alerts (source: Ruskin [
Furthermore, to be effective, the alarms transmitted by monitoring systems must trigger some degree of cognitive response in health-care providers. This equates to introducing stress and the need for constant vigilance, both of which further heighten the risk of AF [56, 57]. When multiple clinical competing priorities collide, it becomes increasingly difficult for a provider to proactively address all ongoing problems, thus forcing them to resort to only partially addressing acute issues while at the same time disrupting other (parallel) activities due to multitasking [58, 59, 60, 61]. Consequently, an ideal alarm should be perfectly audible and easily recognized by health-care providers working within the patient care unit [8], while at the same time minimizing the amount of stress imposed on the responding clinical staff.
\nThe increasingly complex environment of modern health-care systems has led to several important considerations regarding the practical application of monitoring systems. For example, space-related issues deserve special mention, with overly crowded clinical units creating an abundance of alarm-related stimuli and geographically larger clinical units presenting a barrier to prompt patient access. Elevated acuity and high patient throughput are also important considerations in this context [62].
\nFurthermore, technological advancements facilitated the development of increasingly sophisticated alarm systems, with novel features designed to decrease the nuisance factor of the alert mechanism while preserving the level of overall clinical vigilance [63, 64]. These are intended to provide a range of alarm tones that allow care providers to easily identify and prioritize alarms, typically as high, medium, or low priority. However, the implementation of such systems (e.g., IEC 60601-1-8 standard) has presented challenges in terms of recognizability of melodic alarm tones. More specifically, nurses found it difficult to accurately identify all of the melodic tones signifying high-priority alarms, in addition to the potential for confusion between certain alarm pairs [65]. An example of such phenomenon is presented in
A 62-year-old female was admitted to the local hospital 5 days ago due to chronic obstructive pulmonary disease (COPD) exacerbation. She was diagnosed with COPD several years prior and remained stable with no history of exacerbations until 1 week ago when she developed a progressively worsening cough. Soon after her symptoms worsened, she began to feel shortness of breath that was not relieved by rest. At this point, her family insisted she go to the hospital for evaluation. Upon arriving in the emergency department, short-acting bronchodilators and oral corticosteroids were administered with only mild symptomatic improvement. Given the patient’s dyspnea at rest, as well as decreased oxygen saturation of 86%, she was admitted to the pulmonology unit. Supplemental oxygen and intravenous corticosteroids were administered.
\nAt admission, continuous pulse oximetry monitoring was started. The patient’s hypoxemia seemed to improve slightly over the next 4 days, with oxygen saturation climbing to 88–90% range. Still, the patient’s ventilatory monitor sent alarm signals to the hospital staff several times an hour due to high respiratory rate and episodic oxygen desaturations. Alarm signals were transmitted as either a single low tone (respiratory rate) or a double alarm (desaturations), alternating between low and medium tones. The difference of alarm tone indicated the range in which the patient’s oxygen saturation was measured, but the assigned night-shift nurse found the tones to be too difficult to distinguish and would routinely just perform an in-person check of the saturation level upon entering the room. Throughout the first two nights, the same nurse responded to the alarms in a timely fashion, only to find the patient stable and with no signs of acute distress. Assuming that alarms are unlikely to represent any actionable clinical events, the same nurse then began to silence the sounds and began checking on the patient hourly. In the early morning hours of the fourth day, the nurse silenced the alarm once again, intending to assess the patient once the remainder of her rounding routine was completed. When the nurse finally came to the patient’s room an hour later, she found the patient unresponsive and cyanotic. A rapid assessment showed an oxygen saturation of 79%. The patient was immediately intubated, transferred to intensive care unit, and mechanical ventilation was initiated.
\nA 65-year-old male with a history of osteoarthritis of the right knee and refractory pain underwent preoperative evaluation by an orthopedic surgeon. Given his adequate performance status and lack of comorbidities, the patient was determined to be a suitable candidate for total right knee arthroplasty. The surgical procedure was uneventful, with appropriate antibiotic and venous thrombosis prophylaxis administered perioperatively. Following a brief recovery in the postanesthesia care unit, the patient was transferred to the inpatient floor with expected discharge within 5 days postsurgery. Due to the nature of his surgery and apparent fall risk, the patient’s room was fitted with weight-sensitive bed and chair alarms. During the first 3 days, he remained relatively sedated due to the frequent administration of pain medications. However, as the patient began to regain strength, his analgesia regimen was tapered. On day 4, the concurrent increase in patient’s movement began to trigger his bed monitor to the point where the on-call nurse was receiving nearly constant alarm notifications. Multiple times, the nurse entered to assess the patient only to find him resting comfortably without apparent attempt to leave his bed. Later that night, after leaving the patient’s room, the nurse was unexpectedly assigned to three additional patients due to an unplanned absence of a coworker. As the nurse hurried to assess the new patients, the bed monitor transmitted yet another alarm signal. Annoyed by the repeated negative alarms, the nurse disabled the alerts from the bed monitor, intending to check in after tending to her newly assigned patients. When she finally returned to the patient’s room, she found him sprawled on the floor and writhing in pain. The patient, emboldened by his rapid recovery, had attempted to ambulate to the bathroom without assistance and lost his balance in the process. The intense pain prevented him from reaching the call button on the hospital bed, so he was forced to lie on the floor in pain for approximately 1 h. A subsequent skeletal survey revealed a left hip fracture, which required additional surgery, prolonged hospital stay, and the need for inpatient rehabilitation stay due to temporary disability involving bilateral lower extremities (e.g., right knee arthroplasty and left hip injury).
\nA 71-year-old male with a history of multiple myeloma was admitted to the urgent care center after noticing sudden onset of right lower extremity swelling associated with minor pain. The patient began induction therapy for multiple myeloma approximately 1 year prior, achieving adequate disease control. He was subsequently transitioned to maintenance treatment, which he continued for the past 6 months. Evaluation in the urgent care center with venous duplex studies revealed a deep venous thrombosis (DVT). Because of the patient’s established history of malignancy, the triage clinician opted for hospital admission and therapeutic anticoagulation. While being transferred to the inpatient unit, unfractionated heparin anticoagulation was started. Per standard protocol, monitoring equipment was hastily fitted to the patient for noninvasive measurement of his blood pressure and heart rate. Overnight, the patient remained stable, with some resolution of lower extremity of pain despite persistent swelling. The on-call physician assessed the patient during morning rounds and ordered to repeat venous duplex for the afternoon to evaluate for resolution/progression of the DVT. Of note, throughout the night and into the morning hours, the patient’s hemodynamic monitor had been sending intermittent alarm signals. With the first few alarms, the charge nurse promptly responded and quickly assessed the patient for any signs of instability or distress. However, as the shift progressed, the nurse increasingly dismissed repeated signals as “false alarms” due to a recurring pattern of mildly elevated blood pressure and heart rate secondary to episodic extremity pain. Because the inpatient unit continued to be understaffed during the morning shift, the charge nurse decided to disable the patient’s repeated monitor alarms after the patient was assessed during morning rounds and found not to have any acute issues. It was hoped that this decision would eliminate the distraction of the nuisance alarms. However, during the patient’s routine afternoon assessment, the rounding physician noted cold and diaphoretic extremities with markedly increased swelling. Interrogation of the monitor system revealed progressive bradycardia and hypotension over the past hour. An emergency CT angiogram showed a massive pulmonary embolism, prompting immediate thrombolytic therapy and patient transfer to intensive care. Despite aggressive management, the patient’s shock became refractory, culminating in his death several hours later.
\nThe three hypothetical clinical scenarios outlined above share a common theme: dedicated monitoring systems implemented to ensure early detection of clinical deterioration and thus patient safety were utilized either ineffectively or incorrectly. In all three vignettes, a confluence of factors (environment, patient, medical personnel) subsequently led to AF and then adverse patient outcomes. In the following sections, we will further discuss the phenomenon of alarm fatigue, focusing on its impact on daily clinical practice.
\nAfter the general introduction of AF earlier in the chapter, the authors will now discuss this important concept in greater detail. The phenomenon of AF is multifaceted and includes increased clinician response time with simultaneous decreased response rate that is mainly attributed to excessive stimuli from clinical alarms [8]. Depending on patient acuity and clinical monitoring requirements, typical bedside health-care personnel may be exposed to as many as 1000 alarms during a single shift, of which as many as 95% can be nonactionable and thus do not require immediate clinical determination [8, 66, 67]. Given the multitude of clinical alarms, a provider has to sort through during a typical hospital shift, there will be a natural tendency to potentially dismiss certain alarms as insignificant through rationalization. This phenomenon is described in the literature as the natural human behavioral reaction to “deprioritize signals” that have often been proven to be either false or misleading. Thus, staff may begin reflexively disabling or silencing alarm systems, which could effectively mask other alarms that may be clinically significant [68, 69]. To some extent, this behavioral pattern was seen in all three
Certain other factors have been implicated in the increased incidence and severity of alarm fatigue, including greater staff workload, higher patient acuity, and the complexity of the modern health-care environment [10]. Nurses serve as key frontline staff in most clinical settings and play a pivotal role in overseeing patient care and monitoring. Moreover, nurses are subject to significant occupational stress that can be attributed to multiple causes, including heavy workloads [72]. This stress, as outlined in previous sections of this chapter, certainly influences AF by forcing nurses to instantaneously adjust their work activities (and priorities) according to perceived importance of near constant clinical alarm activity. Our
Because multiple factors contribute to AF, many existing models struggle to fully account for (and address) clinician behavioral patterns seen with AF [75]. At the same time, it should be noted that AF is not unique to clinicians. In fact, a similar phenomenon has also been seen among human operators utilizing automated monitoring systems, such as aircraft pilots and nuclear power plant operators. The excessive number of alarm activations leads to the tendency of operators to ignore alerts, particularly when the monitoring system produces a high rate of false alarms or alerts [75]. For these operational environments, it has also been suggested that increased primary and secondary task workloads have a compounding effect on alarm response degradation that may occur in the setting of low alarm system reliability [76]. Similar to the clinical setting, AF can be associated with serious safety risks and represents a similar barrier to the practical application of automated monitoring systems in other fields (Figure 3).
\nThe word cloud demonstrating the multifaceted phenomenon of alarm fatigue.
Significant percentage of nonactionable alarms in the typical modern clinical environment can lead to the development (and subsequent habituation) of AF. As previously mentioned, AF can be characterized by alarm desensitization, mistrust of alert accuracy/utility, and delay of caregiver response (or even lack thereof). Commonly seen reactions to AF include the deactivation and silencing of systems or adjustment of alarm parameters to decrease the number of alarms. Such reactive behaviors have the potential to result in missed critical alarms, leading to patient morbidity or even mortality. In fact, patient safety considerations associated with AF are among the top items of Emergency Care Research (ECRI) Institute’s Health Technology Hazards list [77, 78]. The subject of AF has been extensively studied, primarily due to its high prevalence across essentially all health-care settings. The underreporting of alarm-related events has been recognized as a challenge, and it should be noted that recorded incidents likely reflect only a small proportion of actual events. Available records from the Joint Commission’s Sentinel Event Database show 98 alarm-related occurrences between January 2009 and June 2012 (Figure 4). Of these reported events, several common alarm system issues (Figure 5) were directly connected to events leading to injury or death (Table 1) [79].
\nAlarm-related events and subsequent results from January 2009 to June 2012 (source: Joint Commission’s Sentinel Event Database).
Major contributing factors of alarm-related events (source: Joint Commission’s Sentinel Event Database).
Falls | \n
Delays in treatment | \n
Delays in ventilator use | \n
Medication errors | \n
Additionally, the US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database has identified 566 alarm-related patient deaths between January 2005 and June 2010 [79]. Reports detailing alarm-related events have prompted thorough investigation into AF and possible strategies to address this important phenomenon in the clinical setting.
\nConsidering the potential for very serious clinical consequences of AF, quality improvement measures have been proposed to help reduce both nonactionable alarm occurrences and the incidence of AF. Successful quality improvement projects must address multiple facets of the overall problem, including root causes that lead to AF (Figure 6). For example, poor usability and lack of user-centered devices have the potential for elevating clinical personnel stress levels, creating unnecessary workload and interjecting workflow inefficiencies into an already tense environment [81].
\nThe different aspects of alarm fatigue that can be addressed through different quality improvement approaches (source: Ref. [
Potential solutions for reducing the incidence of AF include multipronged approaches consisting of staff education, equipment (hardware and software) enhancements, and implementation of more efficient clinical protocols or guidelines [82, 83, 84]. From an educational perspective, it is important to ensure adequate staff education, equipment training, and closer team collaboration to improve patient safety within the existing framework [8, 85]. In addition to staff education, hospital policies have been developed and implemented to more clearly define which staff members are able to change alarm settings, as well as how such changes should be made and documented. Many of these polices have also delegated the responsibility of performing clinical alarm monitoring rounds to a staff member in order to allow for continued review of the application of patient monitoring systems [86, 87, 88].
\nTo address the issues of staff workload, two potential approaches have been proposed. The first approach consists of secondary notification systems. The second option involves the use of dedicated staff to oversee alarms. A secondary notification system involves a specialized network interface that algorithmically facilitates the decision process regarding which alarms will be further communicated or escalated to pertinent downstream clinical staff. Further, this system would also enable the automatic escalation of an alert to another clinician, should the primary recipient fail to acknowledge the alarm within a designated timeframe. The use of staff to oversee alarms, while an expensive option, can give additional support to care providers in the form of dedicated personnel whose responsibility is to continuously monitor patient data trends and alarms from a central station [58].
\nNo matter the solution, all the quality improvement processes require a multidisciplinary approach to address the causes and effects of AF. Only through collaborative efforts can substantial change be accomplished to reduce the number of alarm-related events in health care. In addition to the quality improvement measures taken by hospitals, technological advances have also led to more efficient and practical application of patient monitors in the clinical setting. These advances are directed at the reduction of nonactionable alarms with the goal of decreasing the alarm desensitization associated with AF. The importance of adequate information technology support, including better device designs, must be emphasized. As increasingly efficient and complex monitoring equipment is introduced into the clinical realm, certain phenomena, such as the emergence of “unpredictable code,” may adversely affect computer performance (including the ability to effectively recognize important data patterns) and lead to clinical alerts being missed despite the fact that alert-specific data were clearly and provably present [89].
\nIn general, clinical monitoring is based on a careful balance between sensitivity and specificity of alarm signal recognition, as well as the associated threshold setting required to trigger “alert condition” [90, 91]. Increasing monitor sensitivity helps ensure that truly significant events are not missed, primarily using single-parameter alarms and default thresholds [8]. However, as a trade-off this increases the incidence of nuisance alarms that are nonactionable. This issue may be remedied by the development of “smart alarm systems” that use algorithmic approaches to evaluate multiple parameters prior to determining whether the detected change is truly critical, and only then sending an alert to the operator [15]. This improvement in device specificity would result in significantly fewer false alarms and therefore reduce AF. At the same time, the challenges of “unpredictable code” and “interrupted or corrupt data” have been noted and may represent an important safety issue due to the potential for missing data or data misinterpretation, especially when using memory-intensive applications on devices that are continually operating for prolonged periods of time [89, 92, 93, 94, 95].
\nThe ideal patient monitor would have high sensitivity, as well as high negative predictive value for life-threatening clinical scenarios. This would result in excellent “event detection rate” while reducing the number of false and nuisance alarms. Still, any improvement of sensitivity/negative predicative value for monitors must be accompanied by corresponding adjustment to specificity/positive predictive value, ensuring that clinically significant events are captured efficiently [33]. The accomplishment of the above goals may be possible using the application of artificial intelligence (AI) in monitoring systems, wherein AI would be incorporated into logic-based, decision-making systems. The ultimate goal would be the development of clinical monitoring capabilities that reflect and mirror human cognitive/decision-making processes [37]. In the context of this chapter’s
System | \nDescription | \nApplication | \n
---|---|---|
Rule-based expert systems | \nApplication of expert knowledge from a compiled database to new context and simulation of expert decisions | \nDevelopment of a highly specific patient monitor system with electronic access to data available in a multichannel patient monitor and data management system to detect cardiac disturbances [37, 96] | \n
Neural networks | \nUtilization of artificial neural networks to predict disease presence based on advanced information | \nDevelopment of neuronal network used to detect myocardial infarction early on in patients admitted for chest pain [37, 97] | \n
Fuzzy logic | \nDiffuse processing of exact data that does not indicate an explicit conclusion | \nDevelopment of a monitor system able to diagnose simulated cardiac arrest via evaluation of EKG, capnography, and arterial blood pressure [37, 98] | \n
Bayesian networks | \nSystem used for the estimation of event occurrence based on causal probabilistic networks | \nApplication of system for decision support in cardiac event detection [37, 99] | \n
Applications of artificial intelligence in the development of intensive care monitoring.
Source: Schmid et al. [37].
Given the proliferation of advanced monitoring equipment, AF continues to be a major patient safety issue across modern health-care systems. While technological advances show great promise in improving patient care, significant barriers to more optimal implementations exist, including the ongoing struggle to balance the need for high sensitivity versus the excessive number nonactionable clinical alarms. The high frequency of clinical alerts, especially when combined with heavy clinical workload, is known to have negative effects of hospital staff, including alarm desensitization and subsequent delay and/or lack of caregiver response. The resultant AF poses a serious risk to patient safety and has been associated with significant adverse events, including the need for additional or prolonged hospital care, excess attributable morbidity, and even mortality. Prevention of AF requires a multipronged approach consisting of quality improvement measures, staff training, better equipment management (e.g., monitor threshold adjustments) to reduce false alarms, and focus on optimizing staff workload.
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We discuss the adaptive functions of inhibitory control, as well as evidence that life stress, such as poverty, maltreatment, homelessness, and mental illness, negatively impacts individuals’ inhibitory control and overall self-regulation skills. Moreover, these stressors are known to disrupt the development and functioning of crucial brain systems underlying inhibitory control. Following this review, we discuss a critical thinking skills intervention, BrainWise, which is designed to teach inhibitory and self-regulation skills to children, youth and adults. We describe the implementation of the program, and review evidence for its effectiveness with various populations, including our recent study that demonstrated the success of BrainWise in teaching these skills to homeless men living in transitional housing. Finally, we describe our proposed future applications of this intervention to veterans suffering serious mental health challenges. Our overarching goals are to highlight the importance of inhibitory control and overall self-regulation, the vulnerability of these important skills to life stress, and the promise held by one neurocognitive intervention for improving inhibitory control in high-risk populations.",book:{id:"8938",slug:"inhibitory-control-training-a-multidisciplinary-approach",title:"Inhibitory Control Training",fullTitle:"Inhibitory Control Training - A Multidisciplinary Approach"},signatures:"Marilyn Welsh, Patricia Gorman Barry and Jared M. 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The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. 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He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. 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Dr. Villarreal is the editor in chief and founder of the Revista de Ciencias Tecnológicas (RECIT) (https://recit.uabc.mx/) and is a member of several editorial and reviewer boards for numerous international journals. He has published more than thirty international papers and reviewed more than ninety-two manuscripts. His research interests include biomaterials, nanomaterials, bioengineering, biosensors, drug delivery systems, and tissue engineering.",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:17,paginationItems:[{id:"81751",title:"NanoBioSensors: From Electrochemical Sensors Improvement to Theranostic Applications",doi:"10.5772/intechopen.102552",signatures:"Anielle C.A. Silva, Eliete A. Alvin, Lais S. de Jesus, Caio C.L. de França, Marílya P.G. da Silva, Samaysa L. Lins, Diógenes Meneses, Marcela R. Lemes, Rhanoica O. 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