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Justification of the chosen approach to the development of functional computer monitoring

Proposed by JHSiegel et al. | 33. 35], the system of functional computer monitoring is based on the assumption that the application of the mathematical methodology of cluster analysis allows us to distinguish typical clinical images (as the author himself calls them, patterns [31. 32 |). The pathogenetic basis for determining such clinical images in some critical conditions (trauma, sepsis) was the criteria characterizing the peculiarities of the balance between aerobic and anaerobic metabolic pathways for the synthesis of energy substrates.

The theoretical basis for highlighting this feature of shock pathogenesis was the numerous reports of pathophysiologists and clinicians about the inconsistency between the relatively high oxygen delivery to tissues and its low consumption, typical for critical conditions, including septic shock. on the one hand, and between an increase in the products of anaerobic metabolism (lactate and pyruvate) and a decrease in carbon dioxide production, on the other. In this regard, some violations of the main types of metabolism during the pathogenesis of sepsis are presented as follows.

Exposure to an infectious agent leads to significant metabolic disorders in the body of the victim. First of all, this is characterized by a sharp increase in lipolysis, as the main source of energy resources, which is accompanied by an increase in the level of free fatty acids. The absence (or lack) of the supply of exogenous proteins leads to a pronounced catabolism of muscle tissue proteins.

The pool of amino acids formed as a result of myolysis, moreover, against the background of increased consumption of some of them, differs significantly in its qualitative structure from that in a healthy person. According to some reports, this is one of the factors predisposing to the synthesis of “fake neurotransmitters” [29, 39]. At the same time, there are both experimental and clinical data [19, 27], indicating a direct damaging effect of endotoxin on the oxygen-transporting mechanisms of the cell membrane. Consequently, developing metabolic disorders lead, on the one hand, to a direct blockade of oxygen-dependent metabolic mechanisms in the cell, and on the other hand, to the incomplete oxidation of aromatic amino acids and the synthesis of “fake neurotransmitters”. This serves as the basis for another pathophysiological phenomenon observed in sepsis - the mismatch between the significantly increased cardiac output and vascular bed capacity.

After more than twenty years after the publication of JHSiegel et al. of the first works [31, 32], it can be noted that we have a deeper understanding of the nature of developing metabolic disorders, in particular, the role of the small intestine ecosystem and enteric insufficiency syndrome in the pathogenesis of sepsis. However, the main relationships between metabolic disorders and their pathophysiological reflection in the generalized inflammatory processes on which the development of a monitoring system was based remained the same.

The use of such a pathophysiological base, along with the mathematical apparatus developed by the IBM Research Center, already in 1971 allowed us to distinguish three typical pathological clinical images that embody the clinical-pathophysiological characteristic of the general response to a critical situation in a particular patient at a particular point in time in integral expression. They are called “Pattern A”, “Pattern B” and “Pattern C”.
Eight variables were selected for the study - mean arterial pressure, central venous pressure, cardiac index, arteriovenous oxygen gradient, venous partial pressure of carbon dioxide and oxygen, venous blood acidity in pH units, ejection time (physiological indicator characterizing myocardial contractility) .

These studies were performed in 92 patients with various forms of septic and hypovolemic shock. Each patient had from 50 to 200 data correlated to one time indicator. A total of 2 to 10 studies were performed on the patient.

Describing the mathematical method of isolating the corresponding sample of patients, the authors emphasize [16, 35] that after conducting a cluster analysis and determining these pathological groups, the homogeneity of the groups of the studied patients was determined. As a result, the homogeneity of such groups of patients was achieved by the initial clinical selection — only patients with signs of infection and signs of shock were left, and patients with chronic diseases — cirrhosis of the liver, heart and pulmonary insufficiency — were to be removed. After completing this step, uniformity was confirmed by statistical methods.

The inclusion of patients with primary heart failure who were selected for coronary artery bypass grafting operations necessitated a review of the three profiles obtained and the selection of the fourth in 1972 [32]. As a result, the obtained profiles were correlated with clinical characteristics and were defined as:

- profile of hyperdynamic stress response;

- metabolic disorder profile;

- profile of pulmonary failure;

- profile of heart failure.

Given the need for a more detailed description of the pumping function of the heart, two more were added to the analyzed features. Their use as determinants in cluster analysis has led to the identification of a special profile of primary heart failure. Thus, an array was formed and four typical pathophysiological profiles were identified.

Given the extremely difficult presentation in the eleven-dimensional space, a mathematical apparatus was developed to determine the distance to each of the typical profiles from a particular patient profile at a given time, which allowed us to switch from the eleven-dimensional space to four-dimensional. Taking into account the primacy of metabolic disturbances, it was proposed to study the trajectory of the clinical course in the patient in two-dimensional space, where the ratio of the distance to the profile of “pulmonary insufficiency” to the distance to the profile of metabolic imbalance (a ratio that allows us to assess the severity of the anaerobic component in the metabolism was plotted on the abscissa) energy substrates), and along the ordinate axis, the ratio of the distance to the profile of “cardiac abnormalities” to the distance to the profile of “hyperdynamic stress osovoy response ”, which allows to assess the severity of violations of the primary cardiac function or peripheral vascular network [31].

Between 1979 and 1983, a large number of materials were published that were obtained using this system in clinical practice [10, 34, 36–40]. Unfortunately, the existing shortcomings in the structure of the system, as already indicated above, led to the cessation of its functioning.
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Justification of the chosen approach to the development of functional computer monitoring

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