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When you see beyond monitor. A very nice lecture tells you Why we do diagnostic errors ..with a plenty of real clinical examples…good resource for all residents in all levels to review the basics of Hemodynamic monitoring…and more…I spent more than two month preparing this lecture….it is all about anaesthesia residents teaching….I hope that you will like it Ahmad M. Abou Leila
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When you see beyond
monitors.. The Diagnosis errors and Diagnosis game
Ahmad Abou Leila
PGY5 –Anesthesiology
American University of Beirut
Ahmad M. Abou Leila
Take our monitoring skills to the next level.
Integrate the clinical skills with the monitoring skills
Why we do Diagnosis errors?
1
2
3
4 How to avoid the Dx errors
Ahmad M. Abou Leila
Making Diagnosis errors
Ahmad M. Abou Leila
Common Ahmad M. Abou Leila
Common Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Cognitive Errors
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Perception errors Ahmad M. Abou Leila
When you separate patients from the monitor
Ahmad M. Abou Leila
BP100/52 72 y/o
(Hypotension)
20y/o (normal)
Numbers are meaningless without patients
Ahmad M. Abou Leila
VPB
Renal failure Massive transfusion, SUX in Bed ridden
Check the electrolytes and management
Ahmad M. Abou Leila
VPB
Healthy patients during left lobectomy
Cautery irritation
Ahmad M. Abou Leila
Patient A PaCO2=40
Discharged to floor
Patient B PaCO2=40
Respiratory Acidosis
Ahmad M. Abou Leila
Patient B: pregnant woman After 38 weeks PaCO2 <30
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Regular craniotomy Pituitary surgery TBI
Mannitol Therapy Diabetes insipidus Cerebral salt wasting
Ahmad M. Abou Leila
Mannitol Therapy Diabetes insipidus Cerebral salt wasting
Normal Na Hypernatremia Hponatermia
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Positive test Dose
Healthy surgical patients
HR > 20BPM BP >15 mmHg
T wave amplitude decrease
Ahmad M. Abou Leila
Processing Errors Ahmad M. Abou Leila
Representativeness “miss the atypical features”
Availability bias “Dx according to what available
in our Brain Less available pathology less Dx”
outcome bias “choosing Dx with good
outcomes avoid dx with bad outcome”
Overconfidence Bias
Premature closure
Confirmation Bias
Diagnosis momentum
Ahmad M. Abou Leila
Obese patient ..Lap chole..
Post operative he developed tachycardia and hypotension
JP drain ZERO ..
He was Treated as hypovolemic (voluven,blood,Aline)
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Obese patient ..Lap chole..
Post operative he developed tachycardia and hypotension
JP drain ZERO ..
He was Treated as hypovolemic
(voluven,blood..etc)
Availability bias We see a lot of hypovolemia …ready
available in our minds
Out come bias Hypovolemia better prognosis than PE
It is Hypovolemia Premature closure
Insert A-line and volume administration Confirmation Bias and Dx momentum
Death Ahmad M. Abou Leila
After Spinal anesthesia in asthmatic patient
Patient become Dyspneic and desaturation
The resident explanation
“it is false reading”
Ahmad M. Abou Leila
Patient Turned Blue…and again …
Ahmad M. Abou Leila
Ahmad M. Abou Leila
“it is false reading”
premature closure..
Ahmad M. Abou Leila
38 y/o female patient Preclampsia… C/S under GA… Everything is fine
Post Operative she developed severe Dyspnea
What is your differential ?
Ahmad M. Abou Leila
Pulmonary embolism Aspiration
Tocolytic pulmonary edema Pre-eclampsia Pulmonary edema
Anxiety
Ahmad M. Abou Leila
Not every Postoperative Nausea…..Do EGK to rule out MI
Never get the habit of MED student after Brugada lesson
Every ST elevation has to rule out brugada
Base-rate neglect Bias
the tendency to ignore the true prevalence of a disease
Tendency to Diagnose “exotic “ things
Ahmad M. Abou Leila
To write goo differential list ..you have to answer three questions
Ahmad M. Abou Leila
What is the most common cause?
What is the most serious cause?
What is the most likely cause?
Ahmad M. Abou Leila
Ahmad M. Abou Leila
What is the most common cause?
What is the most serious cause?
What is the most likely cause?
Hpovolemia(bleeding) Epidural anesthesia
Pulmonary embolism Mediastinal shift
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Clamp the Drain……. allow the air to fill the cavity call for Surgeon
Mediastinal shift
Ahmad M. Abou Leila
56 y/o female patient osteoperosis,otherwise healthy…
Kyphoplasty…interventional radiology..LA+sedation PACU Dyspnea
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Pulmonary cement embolism After vertebroplasty Ahmad M. Abou Leila
Ahmad M. Abou Leila
What is the most common cause?
What is the most serious cause?
What is the most likely cause?
Opioid overdose
Pontine hge
Ahmad M. Abou Leila
Most likely ..organopphosprous poisoning
SUXMETHONIUM is CI
Ahmad M. Abou Leila
During transfer of TOF baby after DX cardiac CATH
Baby become cyanotic and saturation dropped to 60
Baby had normal breathing pattern(no labored breathing or obstruction)
Ahmad M. Abou Leila
Ahmad M. Abou Leila
I gave the baby oxygen..but he still blue
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Least likely cause of this desaturation
Most likely cause of cynosis (TET spells)
Ahmad M. Abou Leila
Photo from the BLOG
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
After CSE for Multigravida patient the OB resident informed you that
there is significant FHR abnormalities …..
What you think ?
Patient Placed Right side up and BP
normal…
Still FHR abnormal
What you think ? Rule out Uterine Hypertonus
Ahmad M. Abou Leila
Logistic regression analysis showed the type of analgesia as the only independent predictor of uterine hypertonus (odds ratio 3.526, 95% confidence interval 1.21-10.36; P=.022).
Combined spinal-epidural analgesia is associated with a significantly greater incidence of FHR abnormalities related to uterine hypertonus compared with epidural analgesia
Ahmad M. Abou Leila
Deficient Knowledge Ahmad M. Abou Leila
When heart Pumps Blood into the vessels
Ahmad M. Abou Leila
Vascular system is not straight line …..
Ahmad M. Abou Leila
Vascular system is highly branched system. .with many branches and bifurcations
Ahmad M. Abou Leila
Ahmad M. Abou Leila
A-line tracing in elderly
Ahmad M. Abou Leila
A-line tracing in young
Ahmad M. Abou Leila
Appear during Vasoconstriction
Ahmad M. Abou Leila
Combination of two waves… Higher wave amplitude
Ahmad M. Abou Leila
Aorta
Brachial artery
Dorsalis pedis
As you go Further Pulse amplification Taller systolic peak
Lower diastolic pressure
Ahmad M. Abou Leila
Measured SBP in radial and DP Is 20mmHg higher than
central Aorta
In Shock Vasoconstriction Peripheral pulse
Higher then central
False sense of security
Ahmad M. Abou Leila
Reflects
initial upstroke
Not
blood flow
Change with site
Peripheral augmentation
Not
related to autoregulation
Systolic pressure monitoring
Ahmad M. Abou Leila
MAP-ICP CPP
MAP-CVP/CO SVR
Diastolic pressure-LVEDP coronary
MAP-IAP Abdomen
Systolic Blood pressure didn’t appear in autoregulation
Ahmad M. Abou Leila
Indicator of blood flow MAP
Not affected by Reflected waves
No peripheral augmentation MAP
Main Determinants of autoregulation MAP
Not affected by over Damping and
underdamping MAP
Mean Arterial Blood Pressure
Ahmad M. Abou Leila
Lowest MAP without hypoperfusion
MAP Severe HTN :65 Treated HTN:53
Normal :43
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Better Together Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
bisferiens pulse
initial peak upstroke from rapid left ventricular ejection in early systole
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Pulsus alternan…..Not related to MV
Ahmad M. Abou Leila
Severe vasoconstriction
Elevated DP
Multiple RW
Slow up rise of systolic pressure
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Severe AR HOCM IABP Severe AS and Severe
AR
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
In Aline leveling is not a problem but in CVP is CVP is very small number
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Accurate Zeroing
Ahmad M. Abou Leila
Accurate Zeroing
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Injection of cold saline 1
2
Measure the Temperature change
Entrance of cold saline
3
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
U will not see the regular atrial Pressure wave in the severe tricuspid regurge U will have VENTRICULIZATION of ATRIA
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
SVO2=SaO2-(VO2/COx1.36xHct) X 100
Ahmad M. Abou Leila
Venous oximetry
Reduced venous oxygen saturation better predicts adverse outcome after cardiac surgery than does
cardiac output
Venous oximetry detects organs hypoperfusion (VO2)before organs
ischemia develop
Ahmad M. Abou Leila
It is toooooooooooooooooo complicated Any thing else instead
Ahmad M. Abou Leila
Oxygen saturation in the central line
SVC sampling Central line
ScVO2 is lower SVO2 by 2%-3%
ScVO2 =SVC Brain consumption is
higher than rest of body…SVC less O2
ScVO2 less
SVO2=SVC+IVC IVC more oxygen
SVO2 more
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Current evidence and consensus-based guideline for monitoring and treatment of cardiac surgery patients during the postoperative period in
ICU recommends an ScvO2 > 70% SvO2 > 65%
Ahmad M. Abou Leila
European Multicenter study Critical care 2006,10 R185
Deflaviis et al Minerva anesthesiology 2006
Pearse et al Critical care 2009,9 R694-699
ScVO273
ScVO2 >70
ScVO275
SVO2>70
Polonen et al Anes-Analgesia 2000,90:1052-1059
Ahmad M. Abou Leila
Why venous oximetry?
60% of patient udergoing major surgeries develop intestinal ischemia
SVO2 or ScVO2 directed therapy associated with less postoperative complications and mortality
Small increase with SVO2 associated with significant decrease in the mortality
Ahmad M. Abou Leila
ACT monitoring
Ahmad M. Abou Leila
Ahmad M. Abou Leila
ACT contact activator
Celite
Kaolin
Ahmad M. Abou Leila
Aprotonin inhibit
Celite
Ahmad M. Abou Leila
Prolonged ACT Sub optimal heparin
Ahmad M. Abou Leila
Kaolin containing should be used
Ahmad M. Abou Leila
Muscle relaxants monitoring
Ahmad M. Abou Leila
Tests to assess
recovery
Tests to assess
Depth
Ahmad M. Abou Leila
30 40 50 60 70 80 90 TOF%
Safe extubation
No residual paralysis
Head lift 5sec
Tongue Depressor
test
V or T TOF
Fade detection
V or T DBS
Fade detection
50 HZ Tetanus
Fade detection
100 HZ Tetanus
Fade detect
Always Use quantitative test
Ahmad M. Abou Leila
30 40 50 60 70 80 90 TOF%
Safe extubation
No residual paralysis
Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003;98:1042–8
Ahmad M. Abou Leila
30 40 50 60 70 80 90 TOF%
Safe extubation
No residual paralysis
Caldwell JE. Reversal of residual neuromuscular block with neostigmine at one to four hours after a single intubating dose of vecuronium. Anesth Analg 1995;80:1168–74
Ahmad M. Abou Leila
Patient A Co-oximetry results Oxy Hb 70% Reduced Hb 10 % Carboxy Hb 20%
Patient B Co-oximetry results Oxy Hb 50% Reduced Hb 10 % Carboxy Hb 40%
What will be the SPO2 reading in these two
patients? Both SPO2= 90
SPO2 reads only oxy and reduced
And reads the COHB as Oxy HB
Ahmad M. Abou Leila
Oxygen saturation Gap SPO2-SaO2
OSG<5
Ahmad M. Abou Leila
Oxygen saturation Gap SPO2-SaO2>5
Abnormal Hb not measured by SPO2
Ahmad M. Abou Leila
Link the monitor data to the patient physiology…number alone are meaningless Before you make your diagnoses ASK your self” what else might this be?” what did I miss” Remember the three questions “the Most common” ”The most dangerous” and the most likely” Don’t be overconfident…ask for feedback The most important ting to improve your Diagnosing skills is Read and practice
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Have a nice day
Ahmad M. Abou Leila