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BWH Monitoring Practices
James H. Philip, M.E.(E.), M.D., C.C.E.
CA-1s and others July 18, 2011
Available on BWH Anesthesia Web Site
© Copyright 1987-2011, James H Philip, all rights reserved
BWH Monitoring Practices
James H. Philip, M.E.(E.), M.D., C.C.E. Anesthesiologist and
Director of Bioengineering, Brigham and Women's HospitalMedical Liaison for Anesthesia, Partners Department of Biomedical Engineering
Associate Professor of Anaesthesia, Harvard Medical SchoolPast President, Society for Technology in Anesthesia
.
BWH Monitoring Practices
James H. Philip, M.E.(E.), M.D., C.C.E. Anesthesiologist and
Director of Bioengineering, Brigham and Women's HospitalMedical Liaison for Anesthesia, Partners Department of Biomedical Engineering
Associate Professor of Anaesthesia, Harvard Medical SchoolPast President, Society for Technology in Anesthesia
.
Please mentally substitute “Nurse Anesthetist” for “Anesthesiologist” if this applies to you
I invite you to join STA (Society for Technology in Anesthesia)
If you are interested in technology to learn, to invent, to become recognized
Residents and Student memberships are freeSTA headquarters Web Site:www.stahq.org
Part 1 - Monitoring PrinciplesSee full lecture for detailsSame intranet site as thisTitle: Monitoring Principles Slides
Anesthesia = "without sensation"
By loss of sensation, anesthesia allows the patient's brain to tolerate pain that the body was not designed to survive
General Anesthesia
Requires continuous resuscitation during the ongoing administration of lethal drugs
General Anesthesia
Requires continuous resuscitation during the ongoing administration of lethal drugs
Every drug I administer is dangerousTherapy I provide is life-preserving
Monitoring Goal
Protect the patient against adverse outcomes
The Acute Patient Care Loop describes the anesthesiologist’s actions
Patient
measurem
ents Monitor inte
rpre
tatio
n
Anes- thesi-ologist
clinical management
Philip JH Raemer DB.Selecting the optimal
anesthesia monitoring array. Med Instr 1985; 19:122-126.
In the distant past
We monitored our patients using only our sensesA finger on the pulseA hand on the reservoir bagListening to sounds through a stethoscope.Observing color of skin and lips
In the 1960sWe began to monitor the cardiovascular systemWe measured it in many ways
We believed that detecting cardiac arrest fast was important
I was an HP (Hewlett Packard) Engineer back then We really did work hard to detect a stopped heart
We did not yet realize that under anesthesia cardiac arrest is almost always the result of lack of ventilation or lack of oxygen
For a long time without detection
In the 1970s we learned
Most anesthesia mishaps are due to human errorEquipment contributes little to the problemBetter designed equipment detect errorsVigilance aids can improve outcome
by detecting problems before cause harmThis applies especially to airway problems
Cooper JB. Critical Incident Studies (Anesthesiology) 1976-1990. (Harvard Anes. Data)
The greatest danger was circuit disconnection
Which we could easily miss with the technology we had, then
Especially at times of decreased vigilance
In the early 1980s patients learned
Anesthesia is dangerous1,000 times more dangerousthan in an airplane 30,000 feet in the air.
ABC Television 20/20 Report, 1982
In the 1980s anesthesiologists learned
Two monitors could make a differenceCapnography (airway CO2) detects many
problems earlyPulse oximetry detects most problems, but
does so lateStandards could improve outcome
Philip JH Raemer DB. Selecting the optimal anesthesia monitoring array. Med Instr 1985; 19:122-126.
1985 Harvard Anesthesia Monitoring Standard
1) Continuous presence of a dedicated anesthesia care provider
2) Blood pressure and heart rate CV measured & recorded at least every five minutes
3) Electrocardiogram ECG continuously displayed4) Circulation continuously monitored - any technique5) Ventilation continuously monitored - any technique6) Disconnect-detecting device used during mechanical
ventilation7) Oxygen in the breathing circuit monitored with alarm8) Temperature monitoring capability
JAMA, Aug 22/29, 1986Vol. 256, No. 8 Anesthesia Monitoring Eichhorn et al 1017
Standards for Patient Monitoring During Anesthesia at Harvard Medical SchoolJohn H. Eichhorn, MD; Jeffrey B. Cooper, PhD; David J. Cullen, MD; Ward R. Maier, MD;James H. Philip, MD; Robert G. Seeman, MD
JAMA, Aug 22/29, 1986Vol. 256, No. 8 Anesthesia Monitoring Eichhorn et al 1017
Standards for Patient Monitoring During Anesthesia at Harvard Medical SchoolJohn H. Eichhorn, MD; Jeffrey B. Cooper, PhD; David J. Cullen, MD; Ward R. Maier, MD;James H. Philip, MD; Robert G. Seeman, MD
The Boston GlobeVol. 230; No. 53 Friday, August 22, 1986
Anesthesia Safety Saving LivesNine doctors hope others will adopt standardsBy Judy ForemanGlobe Staff
As many as 1400 anesthesia deaths could be avoided each year if doctors nationwide abided by minimal but strict safety standards, says a team of nine Harvard doctors in a new report.
Boston Globe front page headline could have read
Sloppy docs mop shoporKiller docs - cleaning up their act
too little and too late
We were fortunate. The press was supportive
1986 ASA Monitoring Standard
Extended the Harvard Monitoring StandardEncouraged the use of
Pulse Oximetry Capnography Airway gas flow or volume
1989 Amendment to ASA Mon. Std.
Required pulse oximetry to assess blood oxygenation during general anesthesia.
Later Amendments to ASA Mon. Std.
Required CO2 measurement to verify correct placement of the tracheal tube.
Required CO2 monitoring throughout case unless impossible
http://www.asahq.org and navigate to: Health Care Professionals Standards, Guidelines, Statements Basic Anesthetic Monitoring, Standards for (Effective July 1, 2011)
Most authorities believe
Anesthesia mortality has fallenfrom 1/ 3,000 in 1985to 1/ 30,000 or 1/300,000in 1996 (and has remained there)
ICPAMM Report, 1996 (Intl Comm Peri-op Anes M&M)
Most authorities believe
Anesthesia mortality has fallenfrom 1/ 3,000 in 1985to 1/ 30,000 or 1/300,000in 1996 (and has remained there)
1/295,118 = 6
Most authorities believe
Anesthesia mortality has fallenfrom 1/ 3,000 in 1985to 1/ 30,000 or 1/300,000in 1996 (and has remained there)1/295,118 = 6 Anesthesia is a Six Sigma Specialty™
Anesthesia insurance rates
fell and remained stableYear Cost1980 $20,0001990 $10,0002000 $10,0002005 $10,0002010 $10,000
Anesthesia insurance rates
fell and remained stableYear Cost1980 $20,0001990 $10,0002000 $10,0002005 $10,0002010 $10,000
Why?
Anesthesia insurance rates
fell and remained stableYear Cost1980 $20,0001990 $10,0002000 $10,0002005 $10,0002010 $10,000
Why?We stopped hurting people!
Most anesthesia injury & death today is caused by
Failed airway managementMany require additional resourcesIncluding
Equipment, supplies, help, consults LMA (laryngeal mask airway) Special intubating scopes & devices Surgical Airway
Most anesthesia injury & death today is caused by
Failed airway managementAirway and CV complications may
occur with regional anesthesiaHigh Spinal or High Epidural blockIntravascular InjectionUnconscious sedation
Again,
Part 2 BWH
Monitoring Practices
Monitoring PracticeCardiovascular Monitor GE Solar 8000Gas Monitor (Fi O2 , pET CO2 , Anes gases) ADS* or Solar SAMVentilation Monitor ADS* Flow, Vol, PressureNeuromuscular blockade
with paralytic drugs NMB MonitorBrain Monitor, when indicated BIS, SedLineSpecialty-specific monitors Cerebral O2 , EEP
*ADS = Anesthesia Delivery System = Anesthesia Machine + Breathing Circuit
Physiologic Monitor
GE brand is standard throughout Hospital General Electric
Solar and Dash are the models (OR, ICU, Floors)Generally OKOccasionally problematicBeware of Alarm Silence / Pause
Publicized MGH Death January 2010 Not in OR Alarms were turned off
Alarm Silence / Pause - OR Mode
SILENCE ALARM key functions as followsPress x 1 = 5 minute pausePress x 2 = 15 minute pausePress x 3 = permanent pause Press x 4 = alarms on, again
Select New Case Setup for each case
Avoid incorrect alarms, intervals, filters, etc.
Select New Case Setup for each case to avoid incorrect alarms, intervals, filters, etc
This is yesterday’s case and monitor has not been reset to New Case
More menus
Main Menu
New Case Setup
ECG for OR5 LeadsRA, LA, LL for I, II, IIIRL as reference leadV5 as lateral V lead
RALA
LLRL
V5
ECG for PACU5 LeadsRA, LA, LL for I, II, IIIRL as reference leadV5 as lateral V lead
Expedient and convenient
RALALLRL V5
LEADS DISCONNECTED means,
Cable to Block is disconnectedCable is disconnected from monitorTwo leads are disconnected somewhere
In pastRight Leg pad disconnected from skin after moving patientRight Leg Lead is disconnected from pad With new PDM ( Patient Data Module) RL is no longer special
Trim Knob and Quick Keys
NIBP, NBP (noninvasive blood pressure)
Don’t use Go/Stop quick key to start monitoring Go/Stop measures once and only once
Press AUTO for NBP
Set interval to, 1 min, 2 min, 2.5 min, 5 minNIBP Monitoring starts automatically
STAT NBP button
Measures NBP as frequently as it canTypically every 20 secondsAfter 5 minutes reverts to previous Auto Interval Use at times of observed or expected change
STAT mode NIBPs
STAT NIBP helps understanding
Observe Trends with Quick Keys
Select three patient parameters for graphs
Not an easy task
Select patient parameters for graphs - press:
More menus Patient Data Graphic Trends Select Parameters Unselect 3 unwanted ParametersSelect 3 wanted ParametersExample: Select CO2, O2, AgentChange Time Period Select Time Period 6 minutes Beautiful gas trendsWhat a pain !
More menus
Graphic Trends
Select Parameters
Unselect unwanted Parameters
Unselect the ones you don’t want
Select the ones you do want CO2, O2, Agent , here
Change Time Period
Select Time Period 6 minutes
Beautiful gas trends - 6 minutes tells all
Beautiful gas trends - 6 minutes tells all
Tabular Trends with one Quick Key
Tabular Trends
Move between Tabular and Graphic Trends
Make other adjustments that are easier
SpO2 Averaging Time is 2 seconds
SpO2 Averaging Time is 8 seconds in other locations in Hospital
8
Gas Monitoring
SAM (Smart Anesthesia Multi-Gas) ModulePress “PUMP” to get a head start
SAM Module
BTW, Exhaust connects elsewhere
BTW, Exhaust connects elsewhere
Breathing Circuit (Apollo, some Fabius)Scavenger interface and WAGD* system (other Anes Machines)
Gas Monitoring
SAM (Smart Anesthesia Multi-Gas) ModulePress “PUMP” to get a head start Otherwise,
sample gas pump draws 50 mL/min waits to see CO2 misses the first breath or two Then draws 300 mL/min Continuosly measures and graphs gases Identifies agent and continuously measures it
Gas Monitoring
SAM (Smart Anesthesia Multip-Gas) ModulePress PUMP to get a head start on monitoringMonitors
CO2 – waveform, rate, Insp, Exp (End-Tidal) Oxygen - Insp, Exp (End-Tidal) Nitrous oxide – Insp, Exp (Ednd-Tidal) Agents – Iso, Sevo, Des
Iso and Des are hard to differentiate Absorb similar spectra in IR range Auto defaults = Iso.
Gas Display
Has trouble differentiating Isoflurane from Desflurane
Both have similar Infrared AbsorbsionUser much choose between themIsoflurane is the default between these two
Gas Display Iso
Select Des if you will use it and not Iso
Des has been targeted for decreased use
Choose between Iso & Des
Trim Knob and Quick Keys to Choose Gas
Lots of adjustments
Learn themUse themBe carefulAdmit New Patient
to return to BWH OR Defaults
Don’t adjust ECG Filter unless you have a real need for it
ECG Filter can be set
Select ECGSelect ECG
Filter window opensFilter window opens
Here, I changed ECG Filter to Maximum, mid-screen
Monitoring Maximum Filter
GE Idiosyncrasies
Sevo MAC and MAC Fraction are wrongMAC = 1.7% but should be 2.1%All other montitors are correct
GE Idiosyncrasies
Sevo MAC and MAC Fraction are wrong MAC = 1.7% but should be 2.1%
After 96 NIBPs, the 97th throws away the firstNIBP cannot be displayed on 6 minute trend graph
Web lecture shows some additional pictures
Anything wrong here?
Anything wrong here?Sevo MAC Fraction is wrong
Sevo MAC is wrong
96 NIBP max97th NIBP throws away the first one
96 NIBP max
97th NIBP throws away the first one
6 minute Trend is limited
OK for Gases I and E (ideal for this)NIBP cannot be displayed on this time scale
6 minute Trend is limited
6 minute Trend is limitedGreat for gases on 6 minute period
6 minute Trend is limited
NIBP trend cannot be displayed in 6 min window
Default Trend Choices are limited
You must choose parameters by hand
Learn More
Anes Department Intranet Site (Anes Dept only)http://bwhanesthesia.orgEducationAnesthesia Technology
Anes Department Internet Site (public)http://etherweb.bwh.harvard.edu/education/resources/overview.php
Anesthesia Technology
Thank you