1. A COMPLEX SYSTEMS VIEW OF SEPSIS: IMPLICATIONS FOR NURSING LTC Elizabeth A. Mann-Salinas, PhD, RN, CCRN, CCNS 1,2 Joan Engebretson, DrPH, AHN-BC, RN 2 Andriy Batchinsky, MD 1 1 US Army Institute of Surgical Research, San Antonio, TX 2 University of Texas Health Science Center, Houston

2. Complex Systems Non-linear Coupling Sensitivity to initial conditions Self-similarity Emergence Adaptability Self-Organization Connectivity Robustness

3. Complicated Light bulb changer Linear

4. ComplexNon-Linear

7. Coupling 1 + 1 = 3

8. Sensitivity to initial conditions

9. Self-organization

10. Fractals

11. Self-similarity

12. Emergence Novelty Irreducibility to component parts Unpredictable

13. Adaptability

14. Connectivity

15. Robustness

16. Intra-patient variability

18. Bone et al. /

20. Sepsis as a Complex System Non-linear Coupling Sensitivity to initial conditions Self-similarity Emergence Adaptability Self-Organization Connectivity Robustness

21. Sepsis

23. IV Immunoglobin Corticosteroids Xigris ™ Organ Support Early Appropriate ABX

24. SurvivingSepsisCampaign

25. Surgical Intensive Care Unit USNS Comfort Hospital Ship, Persian Gulf, 2003

26. Pattern Recognition Data display “Sniffers” Smart alarms Computer decision support systems

27. Traditional Data Display

28. Novel Data Display

29. “Sniffer”

30. Smart Alarm Date : 13-Mar-11 11:10:09 Bed : 4N-4702 Reasons: Less than 0.5 ml/kg per hour for more than 6 hours UOP for hour 11:00 = 0.0 ml/kg UOP for hour 10:00 = 0.0 ml/kg UOP for hour 09:00 = 0.0 ml/kg UOP for hour 08:00 = 0.0 ml/kg UOP for hour 07:00 = 0.0 ml/kg UOP for hour 06:00 = 0.0 ml/kg Vital Signs at 13-Mar-11 11:10:09: Heart Rate = 129 bpm Blood Pressure: Systolic = 98 mmHg Diastolic = 63 mmHg MAP = 73 mmHg Last Serum Creatinine = N/A Attending Physician Email: david.zonies@amedd.army.mil This email is automatically generated. Questions can be directed to Dr. Jose Salinas. Tel: 210-916-0806 or jose.salinas@amedd.army.mil. NOTE: The information contained in this message may be privileged and confidential and protected from disclosure. If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify Dr. Jose Salinas immediately and delete it from your Computer. david.zonies@amedd.army.mil210-916-0806jose.salinas@amedd.army.mil

31. AUTOMATED CARE “Go to Closed Loop Resuscitation” DECISION SUPPORT “Stop bleeding & give 2 units of plasma” INFORMATION “85% likelihood needs Life-Saving Intervention” DATA “Heart rate 120, blood pressure 96, lactate 4, base deficit -6…” CDSSCDSSCDSSCDSS

32. WVSM

33. Burn Resuscitation CDSS

36. Is sepsis a complex system?

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