Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial

PURPOSE: We studied the effects of reorganization and changes in the care process, including use of protocols for sedation and weaning from mechanical ventilation, on the use of sedative and analgesic drugs and on length of respiratory support and stay in the intensive care unit (ICU). MATERIALS AND METHODS: Three cohorts of 100 mechanically ventilated ICU patients, admitted in 1999 (baseline), 2000 (implementation I, after a change in ICU organization and in diagnostic and therapeutic approaches), and 2001 (implementation II, after introduction of protocols for weaning from mechanical ventilation and sedation), were studied retrospectively. RESULTS: Simplified Acute Physiology Score II (SAPS II), diagnostic groups, and number of organ failures were similar in all groups. Data are reported as median (interquartile range).Time on mechanical ventilation decreased from 18 (7-41) (baseline) to 12 (7-27) hours (implementation II) (P = .046), an effect which was entirely attributable to noninvasive ventilation, and length of ICU stay decreased in survivors from 37 (21-71) to 25 (19-63) hours (P = .049). The amount of morphine (P = .001) and midazolam (P = .050) decreased, whereas the amount of propofol (P = .052) and fentanyl increased (P = .001). Total Therapeutic Intervention Scoring System-28 (TISS-28) per patient decreased from 137 (99-272) to 113 (87-256) points (P = .009). Intensive care unit mortality was 19% (baseline), 8% (implementation I), and 7% (implementation II) (P = .020). CONCLUSIONS: Changes in organizational and care processes were associated with an altered pattern of sedative and analgesic drug prescription, a decrease in length of (noninvasive) respiratory support and length of stay in survivors, and decreases in resource use as measured by TISS-28 and mortality.

MINLP Model for the Synthesis of Heat Exchanger Networks with Handling Pressure of Process Streams

This paper introduces a new mathematical model for the simultaneous synthesis of heat exchanger networks (HENs), wherein the handling pressure of process streams is used to enhance the heat integration. The proposed approach combines generalized disjunctive programming (GDP) and mixed-integer nonlinear programming (MINLP) formulation, in order to minimize the total annualized cost composed by operational and capital expenses. A multi-stage superstructure is developed for the HEN synthesis, assuming constant heat capacity flow rates and isothermal mixing, and allowing for streams splits. In this model, the pressure and temperature of streams must be treated as optimization variables, increasing further the complexity and difficulty to solve the problem. In addition, the model allows for coupling of compressors and turbines to save energy. A case study is performed to verify the accuracy of the proposed model. In this example, the optimal integration between the heat and work decreases the need for thermal utilities in the HEN design. As a result, the total annualized cost is also reduced due to the decrease in the operational expenses related to the heating and cooling of the streams.

Retrofit of heat exchanger networks with pressure recovery of process streams at sub-ambient conditions

This paper presents a new mathematical programming model for the retrofit of heat exchanger networks (HENs), wherein the pressure recovery of process streams is conducted to enhance heat integration. Particularly applied to cryogenic processes, HENs retrofit with combined heat and work integration is mainly aimed at reducing the use of expensive cold services. The proposed multi-stage superstructure allows the increment of the existing heat transfer area, as well as the use of new equipment for both heat exchange and pressure manipulation. The pressure recovery of streams is carried out simultaneously with the HEN design, such that the process conditions (streams pressure and temperature) are variables of optimization. The mathematical model is formulated using generalized disjunctive programming (GDP) and is optimized via mixed-integer nonlinear programming (MINLP), through the minimization of the retrofit total annualized cost, considering the turbine and compressor coupling with a helper motor. Three case studies are performed to assess the accuracy of the developed approach, including a real industrial example related to liquefied natural gas (LNG) production. The results show that the pressure recovery of streams is efficient for energy savings and, consequently, for decreasing the HEN retrofit total cost especially in sub-ambient processes.

Representations of process parallelisms,

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Binns's justice : Digest of the laws and judicial decisions of Pennsylvania, touching the authority and duties of justices of the peace: including all the required forms of process, docket entries, and fee bills ... The whole law in relation to landlord and tenant; insolvent debtors; elections; and fees: the general enactments of the inspection laws; militia laws; and many other laws: with an infinite variety of law forms ... /

The Magistrate's vocabulary of law terms and law phrases: p. 41-61.

Volumetric calibration of process vessels using digital computer techniques /

The paper describes a procedure for accurately and speedily calibrating tanks used for the chemical processing of nuclear materials. The procedure features the use of (1) precalibrated vessels certified to deliver known volumes of liquid, (2) calibrated linear measuring devices, and (3) a digital computer for manipulating data and producing printed calibration information. Calibration records of the standards are traceable to primary standards. Logic is incorporated in the computer program to accomplish curve fitting and perform the tests to accept or to reject the calibration, based on statistical, empirical, and report requirements. This logic is believed to be unique.

The form of process, before the Lords of Council and Session, observed in advocations, ordinary actions, suspensions : shewing also, the manner of making protestations for remedy in law, and how summons thereon was brought before the Parliament of Scotland : and the way how, since the union, such process is laid before the House of Peers : with the form of process before the Lords of Session, as commissioners appointed by Parliament, for plantation of kirks, valuation and sale of tythes : to all which is prefix'd the present state of the College of Justice, giving an account of the members thereof, and of the order observed by the Lords of Session in judging causes : with the fees and prices of writs paid to the several offices and members of the session : written for the use of students in Spotiswood's College of Law /

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Subtitle varies.

On minimal models of process systems

Minimal representations are known to have no redundant elements, and are therefore of great importance. Based on the notions of performance and size indices and measures for process systems, the paper proposes conditions for a process model being minimal in a set of functionally equivalent models with respect to a size norm. Generalized versions of known procedures to obtain minimal process models for a given modelling goal, model reduction based on sensitivity analysis and incremental model building are proposed and discussed. The notions and procedures are illustrated and compared on a simple example, that of a simple nonlinear fermentation process with different modelling goals and on a case study of a heat exchanger modelling. (C) 2004 Elsevier Ltd. All rights reserved.

Specification and validation of process constraints for flexible workflows

Workflow systems have traditionally focused on the so-called production processes which are characterized by pre-definition, high volume, and repetitiveness. Recently, the deployment of workflow systems in non-traditional domains such as collaborative applications, e-learning and cross-organizational process integration, have put forth new requirements for flexible and dynamic specification. However, this flexibility cannot be offered at the expense of control, a critical requirement of business processes. In this paper, we will present a foundation set of constraints for flexible workflow specification. These constraints are intended to provide an appropriate balance between flexibility and control. The constraint specification framework is based on the concept of pockets of flexibility which allows ad hoc changes and/or building of workflows for highly flexible processes. Basically, our approach is to provide the ability to execute on the basis of a partially specified model, where the full specification of the model is made at runtime, and may be unique to each instance. The verification of dynamically built models is essential. Where as ensuring that the model conforms to specified constraints does not pose great difficulty, ensuring that the constraint set itself does not carry conflicts and redundancy is an interesting and challenging problem. In this paper, we will provide a discussion on both the static and dynamic verification aspects. We will also briefly present Chameleon, a prototype workflow engine that implements these concepts. (c) 2004 Elsevier Ltd. All rights reserved.