A Fuzzy Logic based Decision Support System for Low-flow / Closed-loop Anaesthesia

Belinda Hooper Xiheng Hu

Department of Electrical Engineering University of Sydney New South Wales, 2006, Australia

Gycsrgy Jaros Barry Baker

Department of Anaesthesia University of Sydney New South W,ales, 2006, Australia anaesthetic gases used can offer savings of up to 75% of the price of anaesthetic agents and lessen environmental pollution. It also increases the ability to monitor the physiologic condition of the patient noninvasively, thus, increasing the educational value and clinical understanding of the patients state during anaesthesia. These noninvasive physiological and pharmacological monitoring capabilities provided by LFCLA are considered by the enthusiasts to be the most compelling. Unfortunately, the majority of clinicians have not had sufficient exposure in LFCLA to be comfortable in its use or to fully appreciate its merit. In addition, it requires constant monitoring, manual control and quick decision making by the anaesthetist. However, with improving technologies in monitoring equipment, and increasingly important environmental and hospital cost considerations, there has been a renewal of interest in the use of low flow, minimal flow, and completely closed systems. On-line decision support system would make the delivery of anaesthesia easier and safer. It would free the anaesthetist from routine monitoring of gas levels and allow concentration on the anaesthetic procedure. LFCLA is a system that would accept complete computer assisted automation with much greater benefits to the patient than any other delivery system [Droh & Spintage, 19861. There have been several attempts [Boaden and Hutton, 1986; Boaden et al, 1989; Morris, 1983: Vishnoi and Roy, 19911 to design a Control System for LFCLA but no project has been adopted by the industry as an acceptable solution. These above methods utilise classical control algorithms, which rely on exact and continuous measurements of the control variables. It is obvious thay they are not capable of modelling the nonlinearities and the complexity of the anaesthetists decision-makingprocess. The potential of applying Fuzzy Logic to anaesthetic control is discussed in the ;uticle by Asbury and Tzabar, 1995 [l]. It is considered that Fuzzy Logic can model the anaesthetists cognitive processes and although the use of fuzzy logic in medicine is in its infancy, fuzzy logic techniques are already present in many consumer products.

Abstract
Low flow / closed loop anaesthesia (LFCL.4) is the controlled administration of the minimum amount of respiratory and anaesthetic gases required to anaesthetise the patient. At present, the control procedure is manual, with the anaesthetist visually assessitzg the volume of the reservoir bag and the inspiratory and expiratory gas concentrations. Considering this, the application of f u z y logic to clinical anasethesia seems ideal. The design of such a system is in two stages. The first stage is of a single gas (oxygen) system, operating in an open decision support mode, based otz the expen knowledge of an anaesthetist. Once the design is clinically optimised, the feedback loop will be closed to provide the automatic control of oxygen only. The second stage of the prO]eCt will be the extension of the system to handle other anaesthetic gases. A graphical user interface, intevaced with a software-driven simulation of the controller, was designed to aid the clinical evaluation and to display the system components.

1. Introduction
Low-flow/closed-loop anaesthesia (LFCLA) is a method of anaesthesia delivery which recycles the exhaled inhalation gases back to the patient after eliminating carbon dioxide. To maintain the correct depth of anaesthesia, to control pain sufficiently nad to maintain adequate oxygen supply to the patient, a controlled quantity of anaesthetic agents and gases are added to the recycled exhaled gases. This quantity is dependent on the amount absorbed by the body which in turn is dependent on the bodys uptake and metabolism. This delivery method is in contrast to the present practice of high-flow or open-loop anaesthesia in which the patient receives a constant quantity of gas well above the minimum required level. The advantages of LFCLA are economic, environmental and physiological. The reduction in volume of

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Fuzzy logic has been suggested for application in several areas of anaesthesia. It has been applied to the treatment of hypertension during anaesthesia, [Oshita et al, 19933 and to the control of inspired oxygen in ventilated newborn infants [Sun et al, 19941. To date there is no recorded attempt to control oxygen flow by fuzzy logic, although it has been suggested as feasible and ideally suited for the technique [Martin, 19941. The present project is aimed at designing a decision support system to control the supply of oxygen to the patient during LFCLA, based on estimation of the oxygen volume used by the patient. For the first stage, it w s asa sumed that only oxygen is to be supplied to the patient. This neglects the other gases, such as nitrous oxide which is frequently administered to the patient. Other gases will be incorporated into the system at a later stage. It is envisaged, that after the system has been successful in the training of anaesthetic registrars and has gained their confidence in LFCLA, it will be extended to control all the anaesthetic gases and be fully closed.

control is achieved, that fuzzy logic is a good candidate for the control of oxygen supply during LFCLA. The oxygen concentrations in the inspired and expired gas also help the anaesthetist control the system. Monitoring these, allows the anaesthetist to differentiate between a leak, an overfill, an obstruction, entrainment of air, a metabolic change in oxygen usage, cardiovascular system changes and other miscellaneous problems with the patient or in the anaesthetic circuit.

3. Fuzzy control System design

3.1 The Design Objectives & Requirements
There were three key objectives in the design:To regulate the oxygen flow to the anaesthetics circuit according to the patients oxygen consumption. 2. To detect faults within the system and generate warning alarms when the oxygen supplement values are inappropriately high or low parameters values. 3. To display diagnostic messages for possible faults within the system, inferred from the warning alarms. 1.

2. The principles of LFCLA

During LFCLA, the gases exhaled by the patient are recycled back to the patient and the volume of fresh gas is delivered to the patient to matched the volume of gas absorbed by the body. The changes in oxygen uptake can be seen visually by changes in the reservoir bag [Morris, 19941. The bag reflects the condition of the patient and can provide warnings of potential hazardous events. In an oxygen limited system, the oxygen used by the body (OXUSE) leaves the circuit and be replaced by the oxygen supplied to the circuit (OXSUP). Thus, the oxygen concentration remains constant, ie. OXSUP = OXUSE. Otherwise, the difference between the two values equals the rate at which the bag volume is changing (DELTAVOL). During inspiration the gas moves out of the bag and into the lungs while during expiration the movement is reversed. If the volume in the circuit is unchanged, the volume of the bag will return to the same value each time. However, when OXSUP > OXUSE, the total gas in the circuit will increase and the endexpiratory bag volume (BAGVOL) will increase. On the other hand, when OXSUP < OXUSE, the reverse will occur and BAGVOL will decrease. The changes in BAGVOL and DELTAVOL are estimated by the anaesthetist, visually assessing the reservoir bag, and utilised to adjust the OXSUP. It is done in an approximate manner without knowledge of the exact relationship between the changes in BAGVOL, DELTAVOL and OXSUP. Thus, by experience, the anaesthetist gives a little more or a little less oxygen, according to the values of the two input variables. It is obvious from the approximate way

3.2 Data Acquisition

It was decided to use the knowledge of one experienced anaesthetist in the design the first version of the system. The acquisition was performed in steps :1. The components of the decision-making process and their relative importance, 2. The categorisation of inputs and output parameters, including their data ranges and attributes, 3. The establishment of the series of linguistic rules used to evaluate each output parameter evaluation. Due to the rule of thumb method used and the process being evaluated in the mind of the anaesthetist the acquisition was very challenging and time-consuming due to being a difficult to formulate on paper.

3.3 The Design Structure

The design of the controller is based upon the decisionmaking process of the anaesthetist. Presently the oxygen supplement is controlled empirically by the monitoring of several variables. The gas supply is then manually regulated, according to changes in these variables. From repeated evaluation sessions with experts, it wasclear that the visual observation of the reservoir bag characteristics were the most important part of the anaesthetists evaluation process in determining the required oxygen supplement (see Figure. 1). Other parameters such as oxygen concentration in inspired and expired air

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are important but only play a secondary role when 100% oxygen is used without nitrous oxide.

Figure 1. The control method

To reflect this graded decision-making process, the Control System is divided into two blocks or modules shown in Figure.2. The first module (2 Module 1) determines the required oxygen supplement and possible 'alarming' problems and the second module (FZModule 2 ) determines (if necessary) the cause of the possible 'alarming' problems in the circuit.

ture of the 'alarms' are, thus, determined. This is Z achieved by correlating the output signal alarms from F Module 2 against the oxygen concentration values in inspired (INSO) and expired (EXPO) air, and the bag volume (BAGVOL). The diagnostic messages include obstructions (OBS), overfilling (OFILL), leakage (LEAK), and entrainment (ENTR) in the system and metabolism (METAB) and cardiovascular (CVS) and other (OTHER) problems with patient. Several assumptions were made in the design evaluation. These were that the ciircuit is leakage free, the limeSoda Canister totally absorbs all the carbon dioxide from the circuit, the inhalation agents have negligible effects on oxygen concentrations and circuit volumes, and there is no noise or disturbances in the system.

3.4 Design Completion

The design and implementation of the Fuzzy Logic Control System (see Figure 2) was executed using O'INCA Design Framework. The advantages of O'INCA Design Framework were:- no limit on the complexity of the application; easy to use graphical user interface; support of pure fuzzy logic: built-in simulation and debugging facilities; automatic design validation and error location; available DDE applications for the entire project or individual modules and ease of understanding the hierarchal design and representation. 0' INCA software is designed and supplied by Intelligent Machines, Inc. 1153 Bordeaux Drive, Sunnyvale, CA 94089, USA. The completion of the design involved :1. The determination of Fuzzy Parameter data ranges and attributes, 2. The design of the linguistic Fuzzy Rulebases The design of the Fuzzy Membership function for 3. all inputs and outputs, and The determination of methods of Fuzzification, 4. Inference and Defuzzification.
3.4.1 Parameter data ranges and attributes

OXT'

WGVOL

OBS
OFILL LEAK ENTR

METAB

cvs
OTHER

Figure 2. Fuzzy Logic Control System

The main characteristics of the reservoir bag are the reservoir bag volume (BAGVOL) and the rate of change in the reservoir bag volume (DELTAVOL). These signals are the two input signals to FZ Module 1. From these signals the required oxygen supplement (OXSUP) is inferred. In addition to this output signal, are the two 'alarm' signals (Alarm1 & Alarm2). These alarms indicate the detection of faults within the system. Alarms are detected by the monitoring of the relationship between the two input parameters. If a divergence from the appropriate response occurs in the parameters then a fault is detected and an alarm is generated. Alarm1 and Alarm2 indicate inappropriately high or low values, respectively in the input parameters. The FZ Module 2 is designed to provide beneficial diagnostic messages to the anaesthetist, informing him/her of possible faults detected in the system. The precise na-

The linguistic parameters and labels are determined from the anaesthetists' knowledge base. The parameters BAGVOL, DELTAVOL, INSO, EXPO and OXSUP are divided into fuzzy categories (labels) which reflect the anaesthetists classification of the data ranges (see Figure.3). These categories are :NC = nochange
DS DL DF
IS

=
=

slow I small decrease

largedecrease fast decrease slow / small increase large increase fast increase

IL
IF

= -

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Figure 3 The basic membership function

or examnle the data ranse for BAGVOL is below :

Parameter Description :R e change in volume of the
i percentage

i reservoir bag ......................................................................................................

Unit of Measure :..............................................
Data Range :-

....................................................

Figure. 4 - The block diagram of Fuzzy Module 1

DELTAVOL

i -100 (decrease by 100%)to

i 100 (increase by 100%)
DF

DS

NC

I S

IF

Fuzzy Categories :Category Data Ranges :( lower : middle : upper )

i NC, DS, DL, IS, IL i NC -10 : 0 : lo

1
BAGVOL

IS

NC

lDF(AZ)IDF(A2)1DF(A2)

i DS
DL
i IS

-20 : -10 : 0
-100 : -20 : -10
0 : 10 : 20

i IL

10 : 20 : 100

The warning alarms and diagnostic messages are YES and NO outputs and are classified over a range 0 to 1. This is a commonly used categorisation for YES/NO fns.
3.4.2 The Linguistic Fuzzy Rulebases

Table 1. FAM for Fuzzy Module 1. MODULE 2 The distinct block diagram for the Fuzzy Module 2 is shown in FigureS.

The decision making process of the anaesthetist resembles IF...THEN rules formulated by the anaesthetist to determine the amount of oxygen supplement required and whether an alarm is necessary. The IF...THEN rules were tabulated and are visually represented in FAM form. The FAM is an Fuzzy Associative Memory Bank which presTHEN control rules for the controller. ents a set of IF... The FAM is a technique used to visually simplify the design and optimise of the rule base, and is used for the generation of a rulebase for both modules.
MODULE 1 The distinct block diagram for the Fuzzy Module 1 is shown in Figure.4. The control rules are viewed as linguistic conditional statements and have the protocol where each consists of two antecedents with N control rules, IF antecedent, AND antecedent, THEN consequencek where k = 1, 2, ._., N In Module 1 there are three conditional statements : I BAGVOLk AND DELTAVOLk THEN OXSUP, F IF BAGVOLk AND DELTAVOLk THEN Alk IF BAGVOLk AND DELTAVOLk THEN a k This module includes linguistic rules such as IF a small increase in BAGVOL AND a slow increase in DELTAVOL, THEN there is a small decrease in OXSUP. This knowledge base used for Fuzzy Module 1 is summarised in the FAM in Table.1.
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om
ORLL LEAK ENTR
METAB
BAGVOL

cvs
OTHER

Figure. 5 The block diagram for Fuzzy Module 2

This rulebase is more complicated where the protocol consists of five antecedents with N control rules. In Module 2 there are seven conditional statements : IF A1 AND A2 AND WSO AND EXPO AND BAGVOL THEN OB& IF A1 AND A2 AND INSO AND EXPO AND BAGVOL THEN OFILL,

F A 1 AND A2AND INSO AND EXPO AND BAGVOL THEN OTHEh This module includes linguistics rules such as IF A1 is yes, AND A2 is no, AND B slow increase in INSO, AND no change in EXPO, BACVOL is no change THEN LEAK is yes. A portion of the rulebase is shown below in Table.2.

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Table 2 A portion of the rulebase for F u u y Module 2

3.4.3 The Fuzzy Membership Functions

3.4.4 The Fuzzification, Defuzzification and Inference

The simple linguistic rules that describe the anaesthetists actions and membership functions were tested systematically in several runs. By design some of the system parameters had similar data attributes which meant it could be simplified by eliminating unnecessary duplication of membership functions. A simplified triangular membership function was used and then optimised during testing. An optimised BAGVOL membership function is shown below in Figure.6.
Dala.100
Degree 1

Several methods were tested in the optimisation. The final fuzzication inference composition selected was sumproduct for Module 1 and max-min for Module 2 methods, and the centre of gravity method for defuzzification.

3.5 Optimisation
The optimisation technique utilised the trial and error method. Parameters to be optimised were the control rules and membership functions. The optimisation process was accompanied by the constant re-evaluation of the expert knowledgebase (see Figure.7). There are four important aspects of design:(1) The completeness of the control rules : That the controller generated control for any and all input fuzzy states. The ]possibleomission of a control rule was eliminated by die use of FAM representation of the formulation and design of the linguistic rules. (2) The consistency of the control rules : There cannot be an impllemental andor contradictory information in the control protocols that may lead to unexpected and unsatisfactory results. (3) Interaction of the control rules : Must ensure that all control rules and the fuzzy sets must not be too precise and must cover the range of the universe of control. (4) The robustness of the coatroller : This requires the tolerance of the fuzzy controller for noise and disturbance in the system. Fuzzy sets forming the fuzzy partiuon for the input variable exhibit a certain noise immunity over Boolean counterparts and absorbs a notable portion of noise.
L619

-1 W

-80 011 -6000 -40.00 -10.00 0.00

20.00

40.00 6000 Bo 00

100

Figure.6 The membership function for BAGVOL

change m ihe bag mlume ( % )

Figure 7- The optimisation

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4. The user interface

I
F U M LOGIC D E U S f f l COHTROLLER

PATIENT

ANAESTHETIST

Figure.8 - Fuzzy Logic Decision Support System.

The optimised OINCA driven fuzzy control system is integrated with a Visual Basic interface to produce the Fuzzy Logic Decision Support System (see Figure. 8). The interface performs of data acquisition, display, control and storage. It receives input parameters from the user via the console or datafileand displays these on the Input Display of the PC using dynamic data exchange (DDE) methods. At the controller they are inferred and returned to the Output Display of the user interface. The oxygen supplement, the possible acoustic warning alarms and diagnostic messages are displayed for the user. This system provides a basis for the clinical trial evaluation of the controller and adaptation for real-time clinical usage. Provided with the user interface is a tutorial program with a number of quizzes which are incorporated in the education program of trainee anaesthetists.

the control process. These mass equations are difficult to establish and provide no room for noise interference. Thus the fuzzy controllers are generally more robust. The extensive clinical testing of the controller will continue and the optimisation process will be completed for the regulation of oxygen flow during LFCLA. During clinical testing the Fuzzy controller will be run along side an anaesthetist during a Closed Circuit Anaesthesia. The advised responses to the system given by the controller and displayed on the user interface will be compared to the actual responses of the anaesthetist. It will be necessary to test the controller using a number of anaesthetists and a wide range of patients in order to evaluate adel quately al possible operating conditions. The ultimate extension is for the total integration of the fully optimised Fuzzy control System to the regulation of inhalation gases during LFCLA delivery during clinical anaesthesia. This integration requires the optimisation of the present controller using clinical evaluation, the extension of the controller to include anaesthetic agents and nitrous oxide and its optimisation, and then the integration of the controller with an anaesthetic workstation.

References
A.J. Ashbury & Y. Tzabar, Fuzzy Logic - New Ways of thinking for anaesthesia, British Journal o Anaesthesia, 75(1): 1-2 1995. f B.A. Baker, Low Flow and closed circuits, Anaesth I r t l m Care, 22::341-342, 1994. R.W. Boaden & P. Hutton, The digital control of anaesthetic gas flow, Anaesthesia, 41: 413-418, 1986. R.W. Boaden, P. Hutton, C. Monk, A computer controlled anaesthetic gas mixer, Anaesthesia, 44: 665-669, 1989. R. &oh & R. Spintage, Closed Circuit System and other Innovations in Anaesthesia, Springer-Verlag Berlin Hiedelberg, 1986. T.D. East, J.K. Hayes, W.S. Jordan & D.R Westenskow, Computer controlled anaesthetic delivery, Med. Intsmment, 18: 224231, 1984. D.W. Hawes, D.C Ross, D.C White& RT Wlcch, Servo control of closed circuit anaesthesia,Brit. J. Anaesthesia, 54: 229-30,1982. B.L Hooper, A Fuzzy Control System for the oxygen flow regulation during closed circuit anaesthesia, (1993, Department of Electrical Engineering, University of Sydney, Undergraduate Thesis Project D.A. Linkens, & S.B. Hasnain, Self-organising fuzzy logic control and apllication to muscle relaxant anaesthesia, IEEproceedingsD, 138(3): 274-284, 1991. J.F. Martin, Fuzzy control in anaesthesia [editorial; comment],
Journal o Clinical Monitoring, 10: 77-80, 1994. f

5. Conclusions
This study has demonstrated that the application of Fuzzy Logic to the controlling of LFCLA is an appropriate and a viable one. The imprecise nature of the input data and the non-linear and complex nature of the anaesthetists reponses during LFCLA are ideally suited to the methods of Fuzzy Logic as compared to the classical control systems using PID methods. The resulting controller is elegant and simulates to all specifications. The most obvious benefit in the development of a Fuzzy Controller is that the amount of design time required is significantly reduced. It is not necessary to produce a complex and explicitly defined mathematical model and a Fuzzy controller can be applied successful to ill-defined processes by coding directly in to the control protocol of the fuzzy controller. Thus the knowledge base of the anaesthetist is much more adaptable to the design of the fuzzy controller rather than to the PID or adaptive controllers previously attempted. The adaptive controller has been successful but the controller and design process is complex with a set of mass equations required to solve
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S . Oshita, K. Nakakimura, R. Kaieda, T. Murakawa, H. Tamura, I. Hiraoh [Application of the concept of fuzzy logistic controller for treatment of hypertension during anaesthesia]. [Japanese].

Masui - Japanese Joumal o Anesthesiology 42: 185-9, 1993. f Y. Sun, I. Kohane, A.R Stark Fuzzy logic assisted control of inspired oxygen in ventilated newborn infants, Proceedings - the Annual Symposium on Computer Applications in Medical Care, 756-61, 1994. R. Vishnoi, R.J.Roy, Adaptive control of closed-circuit anaesthesia, IEEE Transactions on Bionredical Engineering, 38::39-47, 1991.

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