anesthesia monitoring practices lecture - pain...

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