The Importance of Diagnostic Instruments in Healthcare

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Diagnostic instruments play a crucial role in the early and accurate diagnosis of various diseases in healthcare. These devices aid healthcare professionals in making an informed decision on the best possible treatment for patients. This article will explore what diagnostic instruments are, their importance in healthcare, and some examples of diagnostic instruments.

What are Diagnostic Instruments?

Diagnostic instruments are tools used by healthcare professionals to accurately diagnose a variety of diseases and medical conditions in patients. These advanced instruments are carefully crafted and precisely calibrated to analyze and detect subtle changes and abnormalities within the human body, ensuring accurate and timely diagnosis for optimal patient care.  

Diagnostic tools in healthcare can be classified into two main categories: Imaging equipment and non-imaging equipment.  

Imaging equipment includes advanced technologies like X-rays, MRIs, CT scans, ultrasounds, and PET scans. These tools generate detailed images of internal body structures, aiding in the accurate diagnosis of a wide variety of conditions.  

Non-imaging equipment consists of essential tools like stethoscopes, otoscopes, and thermometers, providing vital information about patients' conditions. The combination of imaging and non-imaging equipment allows medical professionals to comprehensively assess and diagnose medical conditions for optimal healthcare outcomes.

Common Non-Imaging Diagnostic Instruments

Diagnostic tools play a crucial role in diagnosing various diseases and conditions, aiding healthcare professionals in providing accurate and effective treatments. Some common non-imaging diagnostic instruments include stethoscopes, otoscopes, blood pressure cuffs, dopplers, scales, pulse oximeters, and vital sign monitors.  

• Stethoscopes are used to listen to the internal sounds of the body. With their design and amplification capabilities, stethoscopes enable medical practitioners to detect abnormal sounds, such as heart murmurs or lung abnormalities, aiding in the accurate diagnosis of various conditions.  
• Otoscopes are used by healthcare professionals to examine the ears, specifically the auditory canal and the eardrum. They consist of a light source, a magnifying lens, and a funnel-shaped attachment called an ear speculum. These tools are particularly useful in diagnosing ear-related issues, such as infections, blockages, or abnormalities. 
• Blood pressure cuffs, also known as sphygmomanometers, are devices used to measure blood pressure. They consist of an inflatable cuff, a pressure bulb, and a pressure gauge. Blood pressure measurement is a crucial aspect of healthcare as it provides important information about the force of blood against the walls of arteries as the heart pumps it throughout the body, helping healthcare professionals monitor a patient's cardiovascular health.  
• Dopplers are essential tools for measuring blood flow and detecting abnormalities. These portable devices emit and detect high-frequency sound waves, allowing healthcare professionals to assess blood circulation, monitor fetal heartbeat during pregnancy, and diagnose various vascular conditions.   
• Patient Scales are used to measure and monitor the weight of patients. These scales are designed with precision and accuracy, ensuring reliable measurements for healthcare professionals. By providing detailed information about a patient's weight, these scales play a crucial role in assessing and managing their health.   
• Pulse Oximeters are used to measure the oxygen saturation level in a person's blood by clipping onto a finger or earlobe. By emitting light and measuring the amount of light absorbed by the blood, pulse oximetry can provide valuable information about a person's respiratory function and overall blood oxygen levels.  
• Vital Sign Monitors are used to measure and monitor essential physiological parameters, such as heart rate, blood pressure, body temperature, and oxygen saturation levels. These devices play a vital role in healthcare settings, providing healthcare professionals with real-time data to assess a patient's health status and make informed medical decisions.   

Diagnostic instruments play a vital role in the healthcare industry by aiding healthcare professionals in diagnosing medical conditions, especially in their early stages. Early diagnosis leads to early interventions and proper treatment, ultimately preventing disease progression and improving patient outcomes. Ultimately, the use of diagnostic instruments leads to better healthcare delivery in hospitals and clinics, benefiting both healthcare workers and patients.  

Cardiac surgery with cardiopulmonary bypass (CPB) results in a complex inflammatory response attributable to haematological activation (coagulation and protease cascades, platelets, leucocytes) by the extracorporeal circuit. 1 This often results in activation of vascular endothelium, tissue hypoxia and organ injury, particularly in those with pre-existing organ dysfunction. 2 In addition, cardioplegic arrest results in a myocardial-specific ischaemia'reperfusion injury. This can result in low cardiac output post surgery that compounds the tissue hypoxia, inflammation and organ injury attributable to CPB. 3 Organ injury is an important cause of morbidity and mortality and results in an increased use of hospital resources. In a study by Murphy et al. , 4 clinically significant kidney, lung and myocardial injury occurred in 34%, 16% and 11% of patients respectively, contributing to 41%, 36% and 24% of all deaths respectively. Every year, cardiac surgery is performed in > 35,000 UK patients and > 1 million patients worldwide. The number of elderly patients with pre-existing organ dysfunction referred for cardiac surgery increases year on year. 5 Reducing perioperative organ failure therefore presents an ever-increasing challenge for clinicians and health services.

Blood management

The safe and effective management of perioperative anaemia and coagulopathic bleeding is a key determinant of outcome following cardiac surgery.6 Anaemia and coagulopathic bleeding are common, often require multiple blood management interventions and are associated with increases in the rates of organ failure, sepsis and death. However, there is clinical uncertainty as to how these conditions should be managed clinically because of our limited understanding of the underlying mechanisms and the lack of clinical efficacy for most blood management interventions that have been evaluated in clinical trials.7 This has led to significant variability in care.

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Coagulopathic bleeding is a potential complication of every cardiac operation. Death as a direct consequence of bleeding is rare; in the Blood Conservation Using Antifibrinolytics in a Randomised Trial (BART) study, 23 of patients (1%) died of uncontrolled blood loss.8 However, emergency sternotomy for life-threatening bleeding and large-volume blood transfusion (LVBT; >'4 units of red cells) are common and are associated with significant increased risks of organ failure, sepsis and death. LVBT occurs in 22% of UK cardiac surgery patients.9 This has been associated with an eightfold increase in the risk of death.10 Emergency re-sternotomy for life-threatening bleeding or tamponade occurs in 4% of UK cardiac surgery patients and increases the risk of death two- to fivefold.11'13

The causes of coagulopathy are complex and poorly understood but they relate to the activation of platelets and serum proteases by the extracorporeal bypass circuit. These are discussed in detail in Chapter 2. Summaries of interventions in common clinical use to prevent or reverse coagulopathy are described in . The most effective of these is tranexamic acid, a lysine analogue that inhibits the serum protease plasmin, thereby reducing fibrinolysis and promoting clot stability. Tranexamic acid reduces blood loss, transfusion rates and, most importantly, death in cardiac surgery patients.16'18 Other interventions to prevent or reverse coagulopathic haemorrhage reduce blood loss and transfusion but lack the clinical efficacy of tranexamic acid (see ) and their use has declined.22 Transfusion of non-red cell blood components [pooled platelets, fresh-frozen plasma (FFP) and cryoprecipitate] remains the primary treatment for coagulopathic haemorrhage. However, their use is empirical, their risks and benefits are poorly defined and the frequency of their use is highly variable (described in more detail in Chapter 2).

TABLE 1

Summary of the results of systematic reviews and meta-analyses that have evaluated interventions to reduce the risk of acute anaemia or coagulopathic haemorrhage

Identifying those most likely to bleed may benefit patients by allowing preoperative optimisation or the use of targeted blood management interventions such as the reversal of the effects of antiplatelet agents or the reversal of specific coagulation defects identified by laboratory tests or preferably point-of-care (POC) diagnostic tests for coagulopathy. Current guidance recommends that patients undergo careful risk assessment prior to surgery, in combination with POC haemostasis testing to direct therapy in bleeding patients.23,24 Existing bleeding risk scores have significant limitations, however (reviewed in Chapter 3), and are not widely used. Moreover, the evidence to support the use of POC tests is of low quality.25,26 These limitations are reflected by wide variability in the assessment and management of bleeding patients. In a UK audit, 12% of units reported that they did not use POC tests for coagulopathy, 24% reported that they were used in <'25% of cases, LVBT rates ranged from 8% to 35% and emergency re-sternotomy rates ranged from 0.3% to 12%.9 To better define the roles of preoperative clinical assessment and near-patient platelet and viscoelastometry testing for the prediction of severe bleeding, we undertook the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study in a large cohort of adult cardiac surgery patients (see Chapter 2). We hypothesised that the use of near-patient testing would improve the prediction of severe bleeding beyond the use of clinical risk factors alone. We also critically reviewed the limitations of previously published clinical risk scores and developed two new risk scores for preoperative risk assessment (see Chapter 3).

Anaemia, defined as a blood haemoglobin concentration of <'12'g/dl, can be identified in approximately 30% of cardiac surgery patients presenting for surgery in the UK.9 A significant number also develop intraoperative or postoperative anaemia. The most common cause of anaemia is chronic disease (45%), with relatively small proportions of patients presenting with diagnosable and reversible causes of anaemia such as iron deficiency (7%) or vitamin B12 deficiency (11%).27 Additional aetiological factors for intra- and postoperative anaemia are haemodilution, haemorrhage or impaired erythropoiesis. It is hypothesised that anaemia contributes to organ failure and death by reducing tissue oxygen delivery during CPB, resulting in hypoxic cellular injury and organ dysfunction.28 Organs with high metabolic demands are considered more susceptible to injury in the presence of anaemia and there are strong associations between perioperative anaemia and kidney, myocardial and brain injury.29,30

Preoperative interventions for the treatment or reversal of anaemia have limited clinical benefit (see ) and the preferred treatment for acute perioperative anaemia is red cell transfusion. The severity of anaemia, or haemoglobin threshold, that triggers a red cell transfusion differs between clinicians and units. As a result, red cell transfusion rates vary widely. In the UK, red cell transfusion rates range from 32% to 75% in different centres.9 In the USA, rates range from 45% to 92%.31 This is potentially important as red cell transfusion is strongly associated with increased rates of postoperative organ failure and death (see ). Transfusion is also associated with an increased frequency of sepsis.32 It has been hypothesised that these complications are the result of pathological changes that occur in red cells during storage, termed 'the storage lesion', which result in inflammation and organ injury in recipients.33

Differentiating the cause and effect of anaemia on adverse outcomes from those of transfusion is not possible from existing epidemiological analyses because these variables are so strongly linked. Furthermore, in complete contrast to observational studies, randomised controlled trials (RCTs) comparing restrictive haemoglobin transfusion thresholds (6.5'8'g/dl) with more liberal thresholds (8'10'g/dl) suggest that the reversal of anaemia with red cell transfusion may benefit patients. The Transfusion Indication Threshold Reduction (TITRe2) trial4 demonstrated higher mortality in patients randomised to more restrictive thresholds, that is, with more severe anaemia. These observations were supported by the results of a systematic review of this and four similar trials,32 with more liberal transfusion thresholds found to reduce mortality [risk ratio (RR) 0.7, 95% confidence interval (CI) 0.49 to 1.02]. In trials that included only patients with severe symptomatic cardiovascular disease, the reduction in mortality was statistically significant (RR 0.67, 95% CI 0.47 to 0.95; ). This suggests that conditions predisposing to anaemia are the principal contributors to organ failure and death observed in epidemiological analyses, rather than red cell transfusion.

TABLE 2

Summary effect estimates from a systematic review of cohort studies and RCTs considering the relationship between anaemia, red cell transfusion and clinical outcomes

The evidence from randomised trials notwithstanding, clinical uncertainty as to the indications for red cell transfusion in anaemic patients remains. Transfusion guidelines published by the UK National Institute for Health and Care Excellence (NICE)16 recommend more liberal transfusion thresholds in patients with severe cardiovascular disease; however, many other guidelines recommend restrictive thresholds, including those published by the American Association of Blood Banks,34 the Society of Thoracic Surgeons24 and the American College of Critical Care Medicine (ACCM).35 In addition, a limitation of existing 'transfusion trigger' trials is that they compare protocolised transfusion thresholds. It has been hypothesised that the critical haemoglobin level, that is, the threshold below which oxygen delivery becomes impaired, is different both between patients and in individual patients during their perioperative course.36,37 Changes in tissue oxygen requirements are not reflected by protocolised transfusion thresholds and recent commentaries have stressed the importance of more personalised measures of the need for transfusion.38 We evaluate a personalised red cell transfusion algorithm in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial in Chapter 4.

Safer red cells may move the balance of risks and benefits to favour the more aggressive treatment of anaemia. The Red Cell Storage Duration Study (RECESS)39 randomised participants to red cells that had been stored for longer (>'21 days) or shorter (<'10 days) periods of time to test the hypothesis that the storage lesion directly contributed to organ injury. There was no difference between the groups in this trial for the primary outcome of multiple organ dysfunction [95% CI for the mean difference (MD) '0.6 to 0.3; p'='0.44]. This study was limited in that the difference in severity of the storage lesion between day 10 and day 21 red cells is small. Furthermore, epidemiological analysis that compared organ injury and death in many thousands of patients receiving younger red cells or older red cells did not suggest important differences between red cells stored for these different time periods.40 The clinical importance of the storage lesion in transfused patients remains uncertain. In Chapter 5 we consider the effects of an intervention to modify the storage lesion in the REDWASH trial.

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