this series of articles provides regular surveillance of new technologies which may impact on critical care .
several countries have developed national horizon scanning systems to identify and monitor new health technologies .
there is variation in how these centres gather information , but a consistent set of high priority sources has been identified . for the purposes of this article , the outputs of major health technology assessment centres , national regulatory authorities , and recognized scientific news sources ( table 1 ) were systematically searched for developments relevant to acute and critical care
this was combined with a manual medical literature search , along key editorial themes subjectively selected for this issue .
point - of - care testing is a major emerging theme throughout the health sector , encompassing both new diagnoses and monitoring of known diseases and their treatment .
areas of research range from the potentially lucrative markets for outpatient , ' office'-based and patient self - testing , through to in - hospital diagnostics , which include both rapid access analysis of traditionally laboratory bound diagnostics and direct patient imaging .
both aspects are particularly relevant to critical care clinicians , who rely on time sensitive diagnosis and treatment in a hyper - acute setting .
an example of bedside imaging in cardiac assessment has already been cited in the first article of the present series .
sample analysis , meanwhile , is rapidly developing to encompass bedside biochemical markers , physiological homeostasis monitoring , and novel ultra - rapid forms of infectious disease diagnosis .
b - type natriuretic peptide can be a rapid and effective marker of ventricular strain and heart failure , and can now be measured using a point - of - care diagnostic panel ( triage bnp test ; biosite inc . , san diego , ca , usa ) .
similar current and forthcoming technologies include rapid access d - dimer assays for diagnosis of pulmonary embolism as part of a structured point - of - care algorithm   and unpublished early developments in stroke diagnostics .
validation and clinical trials of these technologies have taken place primarily in the emergency department setting , but heart failure , cerebrovascular accident and pulmonary embolism are all of added significance in the intensive care unit ( icu ) as both primary and acquired conditions .
rapid bedside diagnosis of such conditions with minimal need for intrahospital transport may be of great potential benefit to intensivists .
the importance of tight glucose control in sepsis is becoming well established , although work continues on refining the target range , with a study of 4,000 patients now in progress ( normoglycaemia in intensive care study , anzics , commencing 2004 ) .
the first major prospective study of tight glucose control in sepsis introduced a novel algorithm requiring frequent measurements , which raised concerns over patient safety and resource utilization in general icus .
point - of - care ' stick ' glucose testing is already prevalent , but technology now exists for continuous in vivo glucose monitoring , which , although intended for ambulatory use , could improve accuracy in the acute setting . a subcutaneous interstitial glucose sensor system ( continuous glucose monitoring system ; medtronic minimed , inc . ,
northridge , ca , usa ) was tested against clamp controlled hypoglycaemic and hyperglycaemic excursions in volunteers ; it was shown to be closely correlated with reference analyzer results ( r= 0.91 ; p < 0.001 ) and highly responsive ( half - time 4.0  1.0 min ) .
similarly , another device ( glucoday ; a. menarini diagnostics , florence , italy ) , utilizing a 15100 l micropump and a biosensor coupled with microdialysis to give a claimed response time of 2 min , will reach european markets this year . such devices may be incorporated into manual algorithms , or they may potentially open the way to automated closed - loop glucose control . microbiological diagnosis within clinical laboratories has been advancing apace .
polymerase chain reaction technology is well established , but progressive refinements have made possible the rapid and near real - time diagnosis of current , novel , or newly relevant pathogens , including hiv and sars ( severe acute respiratory syndrome ) .
techniques initially aimed at viruses because of their manageable size can now also be applied to bacteria and can be used for broad , simultaneous screening of multiple pathogens ( pneumoplex , prodesse , milwaukee , wi , usa ) .
further refinements in microarrays and microfluidics are anticipated to bring handhand and point - of - care systems into use in the near future .
point - of - care and rapid laboratory based technologies will soon be able to elicit not only pathogen identity but also patterns of drug resistance .
developments include the use of adenylate kinase assay for accelerated laboratory based identification of drug - resistant bacteria , including methicillin - resistant staphylococcus aureus and vancomycin - resistant enterococci ( baclite , acolyte biomedica , salisbury , uk ; ) .
point - of - care testing within emergency and critical care areas is likely to develop rapidly in the next 5 years , but it will bring complications relating to quality control , medicolegal liability , certificated training for icu and other nonlaboratory staff , increased cost , and territoriality issues . finally , other bedside technologies that have recently been assessed include the use of handheld ultrasound devices to detect occult pneumothoraces , which have been shown to have a higher sensitivity than chest radiography ( 48.8% versus 20.9% ) against a computed tomography standard .
preliminary investigations suggest that handheld infrared pupillometry may be of clinical use in detecting midline cerebral shift in head injury patients .
more procedure orientated assistance may become available from near - infrared technology , which has been piloted in a computerized bedside visualization device to aid venous cannulation .
a study of icu patients in calgary   demonstrated crude death rates of 45% among patients with icu - acquired bsi , as compared with 21% in those without ( p < 0.0001 ) .
s aureus was isolated in 18% of cases in the study cited above . in this context , the development of an antistaphylococcal vaccine ( staphvax ; nabi pharmaceuticals , boca raton , fl , usa ) represents a promising new health technology .
staphvax is currently in phase iii trials for end - stage renal disease , but phase ii trials are under way in postoperative and long hospital stay patients .
health technology assessment encompasses the best use of current health care devices as well as emerging technologies .
medical devices represent a prime infection hazard , and us centers for disease control and prevention guidelines   cover the safe use of intravascular devices to minimize acquired bsi .
however more recent work demonstrates that the incidence of catheter - related bsi may be significantly reduced by adding a further device 
needle - free , disinfectable connectors instead of three - way stopcocks  to the existing recommendations ( 0.7 infections/1000 days versus 5.0 infections/1000 days of catheter use ; p < 0.03 ) .
clinical management of sepsis is normally outside the remit of this section of the journal .
however , it is noteworthy that new mechanical technology has been applied to the direct treatment of sepsis rather than to cardiovascular or tissue perfusion monitoring . a recent european multicentre open randomized phase ii trial   investigated the use of the endotoxin adsorber system en500 ( fresenius , bad homburg , germany ) in 145 patients with severe sepsis or septic shock due to suspected gram - negative infection .
the study demonstrated a trend toward reduced icu stay and more rapid reduction in lipopolysaccharide levels , but it failed to show any difference in outcome .
isabel is a web - based , diagnostic decision support tool intended to provide diagnosis reminders and minimize missed diagnosis of critical disease processes .
it is currently in use in several uk and overseas hospitals , with development supported by uk department of health funding followed by a commercial launch .
the methodology is novel ; a commercial artificial intelligence inference engine ( autonomy , cambridge , uk ) is used to extract and structure information from standard paediatric textbooks , and to generate diagnostic reminders from this knowledge base in response to unstructured free text clinical information .
the software has been under development for some time and was reviewed in this journal in 2002 , but it is now being modified to encompass adult critical illness .
a review of decision support systems by the uk national institute of clinical excellence is pending .
the isabel project was initially set up on a charitable basis by the parents of a child who survived a prolonged stay in paediatric intensive care after a missed diagnosis of necrotizing fasciitis .
although the system is as yet little known among adult intensivists , its technology is innovative and its proposed status as an ' online second opinion ' may give it , together with similar expert systems , a powerful consumerist resonance with patients , carers and managers .
the uk national institute of clinical excellence findings should be monitored with interest by critical care providers .
more broadly , the uk health service is currently in the grip of a globally unprecedented large - scale national project for it ( npfit ) .
structured as a series of private finance initiatives , this ambitious programme will ultimately see in a host of regionally standardized patient information systems , image storage , and networked monitoring and audit systems , linked to a national electronic patient record ' spine ' .
broader concern is growing about catastrophic and unpredictable ' emergent behaviour ' in massively interconnected information technology ( it ) systems , which are rapidly becoming too complex to test or accurately model .
emergent behaviour in complex systems has already been explored in popular fictional media , in which predicted outcomes are spectacular but somewhat discouraging ; however , even without quite such an apocalyptic scenario , we may well see a rising incidence of total system failures due to unpredictable nonlinear behaviour  that is , major collapses triggered by small unforeseen causes . in the light of recent north american power outages and destructive computer failures in the uk social service and tax systems , emergent behavour must now be considered a clear and present threat to our increasingly networked health services and their supporting infrastructure .
levels of concern are such that the uk government is funding a  10 million research programme into it complexity and catastrophic failures .
they therefore require the successful convergence of multiple hospital systems , which makes them uniquely vulnerable to the consequences of system failures , whether in diagnostics , supplies , information flow , or indeed electrical power .
second , the currently stated uk npfit vision is that all icu subsystems , including networked monitoring , telemetry and audit systems , will eventually be integrated into npfit , with control over equipment selection and data collection handed to the regional private sector consortia and to national audit bodies .
clinician engagement and choice may not feature highly on the agenda , and there are clear concerns over the future of independent research and audit .
finally , clinicians from other countries would be well advised to follow such developments because the uk is not unique in its desire to radically modernize and standardize health it , starting with a drive toward electronic patient records . in april 2004
, president bush issued an executive order calling for us national implementation of electronic medical records within 10 years , from a current baseline of 19% implementation . in a series of presidential speeches he went on
therefore , this represents another area in which political and technological developments outside the icu may have a direct impact on clinical practice and patient safety , and intensivists are strongly recommended to consult early and engage with those driving their local and national health economy .
very few of these are designed or marketed to be specific to intensive care , and few are traditional ' devices ' that can be physically handled or attached to a patient . however , critical care is a distillation of acute hospital practice , and any health care technology that has an impact on diagnosis , monitoring , and management of acute conditions will be of heightened importance in the clinical pressure cooker of intensive care .
point - of - care testing , accelerated microbiological diagnostics , decision support systems and networked it systems are all key developments that will exert an impact on future critical care practice .
bsi = bloodstream infection ; icu = intensive care unit ; it = information technology .
 this commentary represents a selective survey of developments relevant to critical care . 
 selected themes include advances in point - of - care diagnostic testing , glucose control , novel microbiological diagnostics and infection control measures , and developments in information technology that have implications for intensive care . 
 the latter encompasses an early example of an artificially intelligent clinical decision support mechanism , the introduction of a national health care information technology programme ( uk npfit ) and its implications , and exotic threats to patient safety due to emergent behaviour in complex information systems . 
Introduction
Point-of-care diagnostics and ultra-rapid laboratory testing
Infection and sepsis
Information technology
Conclusion
Abbreviations
Competing interests
Figures and Tables