Anesthesia Monitoring

By

David Roy Godden MSN CRNA

Keck School of Medicine

Objectives

bull Review need for monitoringbull List the essential monitors for general anesthesiabull Identify the most essential monitor in the ORbull Describe the indications contraindications for arterial line

placementbull Identify the techniques for arterial line placementbull List the complications of arterial line placement and

describe trouble shooting arterial line tracingsbull Be able to evaluate an arterial line tracingbull Know what the best monitor in the OR is

Objectives

bull Describe the indicationscontraindications for central line placement

bull Identify the techniques for central line placement

bull List the complications of central line placement and trouble shooting CVP waveform

bull Be able to evaluate the CVP tracing

bull Discuss the BIS monitor and be able to discuss patient awareness during anesthesia

Why Monitoring

bull Monitoring is an essential part of anesthesia care ldquoEffective monitoring reduces the potential for poor outcomes that may follow anesthesia by identifying derangements before they result in serious or irreversible injuryrdquo (Barish 2006)

bull Standard I for monitoring includes 1) the presence of a qualified provider to be present in the operating room at all times to monitor the pt continuously and modify anesthesia care based on clinical observations and responses of the patient to treatments

What to Monitorbull Standard II specifies an oxygen analyzer with a low

concentration limit alarm quantitative assessment of blood oxygenation during anesthesia continuously ensuring the adequacy of ventilation by physical diagnostic techniques during all anesthesia care Quantitative monitoring of tidal volume and capnography are encouraged in all pts undergoing GA

bull Ensuring adequacy of circulation by by a) continuous display of the ECG and b) blood pressure measurements at least Q 5 minutes

bull Pulse quality via palpation is historically the method for evaluating adequacy of circulation Radial pulse = MAPgt60 or so while femoral pulse may be palpated at a lower mean Pre-cordial stethoscope anyone

Monitoring cont

bull Every patient that is endotracheal intubated or has an LMA placed requires qualitative identification of carbon dioxide in the expired gas

bull During GA capnography and end-tidal C02 analysis are encouraged Really encouraged not required

bull For Off site anesthesia care NC oxygen with capnography is ENCORAGED STRONGLY

bull So does every general anesthesia case require an airway You would think so Wait till you get the CHLA

bull Mask Case with general anesthesia require what monitorsbull During all anesthetics the means for measuring a ptrsquos temperature

must be AVAILABLE When changes in a ptrsquos temperature is required or anticipated the continuous measurement and recording of temperature should be done

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Objectives

bull Review need for monitoringbull List the essential monitors for general anesthesiabull Identify the most essential monitor in the ORbull Describe the indications contraindications for arterial line

placementbull Identify the techniques for arterial line placementbull List the complications of arterial line placement and

describe trouble shooting arterial line tracingsbull Be able to evaluate an arterial line tracingbull Know what the best monitor in the OR is

Objectives

bull Describe the indicationscontraindications for central line placement

bull Identify the techniques for central line placement

bull List the complications of central line placement and trouble shooting CVP waveform

bull Be able to evaluate the CVP tracing

bull Discuss the BIS monitor and be able to discuss patient awareness during anesthesia

Why Monitoring

bull Monitoring is an essential part of anesthesia care ldquoEffective monitoring reduces the potential for poor outcomes that may follow anesthesia by identifying derangements before they result in serious or irreversible injuryrdquo (Barish 2006)

bull Standard I for monitoring includes 1) the presence of a qualified provider to be present in the operating room at all times to monitor the pt continuously and modify anesthesia care based on clinical observations and responses of the patient to treatments

What to Monitorbull Standard II specifies an oxygen analyzer with a low

concentration limit alarm quantitative assessment of blood oxygenation during anesthesia continuously ensuring the adequacy of ventilation by physical diagnostic techniques during all anesthesia care Quantitative monitoring of tidal volume and capnography are encouraged in all pts undergoing GA

bull Ensuring adequacy of circulation by by a) continuous display of the ECG and b) blood pressure measurements at least Q 5 minutes

bull Pulse quality via palpation is historically the method for evaluating adequacy of circulation Radial pulse = MAPgt60 or so while femoral pulse may be palpated at a lower mean Pre-cordial stethoscope anyone

Monitoring cont

bull Every patient that is endotracheal intubated or has an LMA placed requires qualitative identification of carbon dioxide in the expired gas

bull During GA capnography and end-tidal C02 analysis are encouraged Really encouraged not required

bull For Off site anesthesia care NC oxygen with capnography is ENCORAGED STRONGLY

bull So does every general anesthesia case require an airway You would think so Wait till you get the CHLA

bull Mask Case with general anesthesia require what monitorsbull During all anesthetics the means for measuring a ptrsquos temperature

must be AVAILABLE When changes in a ptrsquos temperature is required or anticipated the continuous measurement and recording of temperature should be done

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Objectives

bull Describe the indicationscontraindications for central line placement

bull Identify the techniques for central line placement

bull List the complications of central line placement and trouble shooting CVP waveform

bull Be able to evaluate the CVP tracing

bull Discuss the BIS monitor and be able to discuss patient awareness during anesthesia

Why Monitoring

bull Monitoring is an essential part of anesthesia care ldquoEffective monitoring reduces the potential for poor outcomes that may follow anesthesia by identifying derangements before they result in serious or irreversible injuryrdquo (Barish 2006)

bull Standard I for monitoring includes 1) the presence of a qualified provider to be present in the operating room at all times to monitor the pt continuously and modify anesthesia care based on clinical observations and responses of the patient to treatments

What to Monitorbull Standard II specifies an oxygen analyzer with a low

concentration limit alarm quantitative assessment of blood oxygenation during anesthesia continuously ensuring the adequacy of ventilation by physical diagnostic techniques during all anesthesia care Quantitative monitoring of tidal volume and capnography are encouraged in all pts undergoing GA

bull Ensuring adequacy of circulation by by a) continuous display of the ECG and b) blood pressure measurements at least Q 5 minutes

bull Pulse quality via palpation is historically the method for evaluating adequacy of circulation Radial pulse = MAPgt60 or so while femoral pulse may be palpated at a lower mean Pre-cordial stethoscope anyone

Monitoring cont

bull Every patient that is endotracheal intubated or has an LMA placed requires qualitative identification of carbon dioxide in the expired gas

bull During GA capnography and end-tidal C02 analysis are encouraged Really encouraged not required

bull For Off site anesthesia care NC oxygen with capnography is ENCORAGED STRONGLY

bull So does every general anesthesia case require an airway You would think so Wait till you get the CHLA

bull Mask Case with general anesthesia require what monitorsbull During all anesthetics the means for measuring a ptrsquos temperature

must be AVAILABLE When changes in a ptrsquos temperature is required or anticipated the continuous measurement and recording of temperature should be done

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Why Monitoring

bull Monitoring is an essential part of anesthesia care ldquoEffective monitoring reduces the potential for poor outcomes that may follow anesthesia by identifying derangements before they result in serious or irreversible injuryrdquo (Barish 2006)

bull Standard I for monitoring includes 1) the presence of a qualified provider to be present in the operating room at all times to monitor the pt continuously and modify anesthesia care based on clinical observations and responses of the patient to treatments

What to Monitorbull Standard II specifies an oxygen analyzer with a low

concentration limit alarm quantitative assessment of blood oxygenation during anesthesia continuously ensuring the adequacy of ventilation by physical diagnostic techniques during all anesthesia care Quantitative monitoring of tidal volume and capnography are encouraged in all pts undergoing GA

bull Ensuring adequacy of circulation by by a) continuous display of the ECG and b) blood pressure measurements at least Q 5 minutes

bull Pulse quality via palpation is historically the method for evaluating adequacy of circulation Radial pulse = MAPgt60 or so while femoral pulse may be palpated at a lower mean Pre-cordial stethoscope anyone

Monitoring cont

bull Every patient that is endotracheal intubated or has an LMA placed requires qualitative identification of carbon dioxide in the expired gas

bull During GA capnography and end-tidal C02 analysis are encouraged Really encouraged not required

bull For Off site anesthesia care NC oxygen with capnography is ENCORAGED STRONGLY

bull So does every general anesthesia case require an airway You would think so Wait till you get the CHLA

bull Mask Case with general anesthesia require what monitorsbull During all anesthetics the means for measuring a ptrsquos temperature

must be AVAILABLE When changes in a ptrsquos temperature is required or anticipated the continuous measurement and recording of temperature should be done

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

What to Monitorbull Standard II specifies an oxygen analyzer with a low

concentration limit alarm quantitative assessment of blood oxygenation during anesthesia continuously ensuring the adequacy of ventilation by physical diagnostic techniques during all anesthesia care Quantitative monitoring of tidal volume and capnography are encouraged in all pts undergoing GA

bull Ensuring adequacy of circulation by by a) continuous display of the ECG and b) blood pressure measurements at least Q 5 minutes

bull Pulse quality via palpation is historically the method for evaluating adequacy of circulation Radial pulse = MAPgt60 or so while femoral pulse may be palpated at a lower mean Pre-cordial stethoscope anyone

Monitoring cont

bull Every patient that is endotracheal intubated or has an LMA placed requires qualitative identification of carbon dioxide in the expired gas

bull During GA capnography and end-tidal C02 analysis are encouraged Really encouraged not required

bull For Off site anesthesia care NC oxygen with capnography is ENCORAGED STRONGLY

bull So does every general anesthesia case require an airway You would think so Wait till you get the CHLA

bull Mask Case with general anesthesia require what monitorsbull During all anesthetics the means for measuring a ptrsquos temperature

must be AVAILABLE When changes in a ptrsquos temperature is required or anticipated the continuous measurement and recording of temperature should be done

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Monitoring cont

bull Every patient that is endotracheal intubated or has an LMA placed requires qualitative identification of carbon dioxide in the expired gas

bull During GA capnography and end-tidal C02 analysis are encouraged Really encouraged not required

bull For Off site anesthesia care NC oxygen with capnography is ENCORAGED STRONGLY

bull So does every general anesthesia case require an airway You would think so Wait till you get the CHLA

bull Mask Case with general anesthesia require what monitorsbull During all anesthetics the means for measuring a ptrsquos temperature

must be AVAILABLE When changes in a ptrsquos temperature is required or anticipated the continuous measurement and recording of temperature should be done

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

The Five Alarmsbull During routine anesthesia care a minimum of 5 alarms must

be in usebull Inspired oxygen and a low O2 limit alarmbull Airway pressure limit alarmbull Oximetrybull Blood pressure limit alarmbull Heart Rate limit alarmsbull Often too many alarms just cause confuse confusion When

were you last in the ICU with alarms going off continuously bull The Pulse Oxygen Tone must be monitored continuously

Make sure that the volume of the tone is adequate for you

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

What is the Best Monitor

bull I want you to think about all of the monitors that you have available and try to decide which is the most useful or most essential to provide safe anesthesia care

bull Is it the ECG or the Blood Pressure What about monitoring adequacy of ventilation with capnography

bull You must decide what is the most essential

bull What could you do without

bull Do you consider the pre-cordial stethoscope an essential monitor If so why What info does the pre-cordial give you about the patient

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Best Monitor

bull Any biomedical engineer can design more monitors The list is potentially endless

bull However nothing replaces the presence of a Vigilant anesthesia provider

bull You are the Best Monitor of a patients condition during General Anesthesia

bull Through the use of visualization palpation and auscultation the anesthetist can monitor the adequacy of circulation ventilation and temperature The use of technology increases your ability to do this monitoring quickly and efficiently but none of these advances replace YOU Be watchful Pay attention Look at the Patient

bull Use the pre-cordial stethoscope bull So whats the best monitor

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Arterial Lines

bull Indications for arterial line placement includendash The need to continuously monitor a pts blood pressurendash In ASA class III or IV patient (relative indication) or

ldquosickrdquo patientsndash When frequent blood draws are anticipatedndash When ABG evaluation in requiredndash Expected blood loss is high or the need to monitor Hct

with expected blood administrationndash Vascular cases or cases when a hypotensive technique

is usedndash If continuous vasoactive medications are required

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Contraindications to Art Line

bull Patient refusal Discuss options with patient

bull Selection of cannulation site requires attention

bull Choice of site by location First use radial then DP (dorsalis pedis) then femoral lastly brachial Why

bull If there is infection at the site of entry then donrsquot go there

bull Ischemia in an extremity with inadequate blood flow

bull Large thrombus at chosen entry site

bull What is the Allenrsquos test

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Radial Artery Cannulation

bull The Allenrsquos Test do we routinely use it bull In the past the patency of the ulnar artery circulation by

the performance of the Allenrsquos Test has been recommended before cannulation

bull The Allenrsquos Test is performed by compressing both radial and ulnar arteries while the patient tightens his or her fist Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand

bull The prognostic value of the Allenrsquos Test in assessing adequacy of the collateral circulation has NOT been confirmed

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Allenrsquos Test

bull The arteries of the hand both the radial and ulnar have collateral circulation

bull The predominant circulation of the hand is supplied by the ulnar artery in most patients

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Arteries of the Arm

bull Note brachial artery small collaterals

bull Radial is larger and more superficial artery than Ulnar

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

NIBP vs Arterial Cannulation

bull NIBP (auscultatory oscillometric)

bull Prosndash Healthy patientsndash Short case

bull Consndash Bladder cuff sizendash Flow dependentndash Motionndash Interruption of IV infusionndash Injuryndash Cuff deflation ratendash Hydrostatic errors

bull Arterial Cannulationbull Pros

ndash Continuous BPndash Sick patientsndash Difficult casesndash ABG monitoring

bull Consndash Nerve dysfunctionndash Thrombosis Ischemiandash Hematoma formationndash Infectionndash Hydrostatic errors

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Art Line Placement Techniques

bull Sterile prep and sterile towel Wash hands vs Surgical scrub and the use of sterile gloves always

bull Betadyne vs Chloroprep for skin preparation

bull Dr Sven-Ivar Seldinger (1921-1998) developed a technique for arterial or venous cannulation

bull IV method is very slick Watch Kari Cole or Terrie Norris they are great with this technique me Irsquom lame

bull Arrow Kit is in cart This technique uses a very sharp needle and soft cannula which is best for longer term use

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Seldinger Technique

bull Dr Sven-Ivar Seldinger (1921-1998)

bull Use 20 ga needlecannula to transect artery

bull Remove needle and thenbull Draw cannula back slowly till

free flow of arterial blood occurs

bull Pass wire into artery down needle

bull Thread cannula over the wirebull Easiest method

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Art Line Complications

bull Thrombus formation

bull Arterial laceration

bull Hematoma

bull Loss of distal perfusion to handhellipouch

bull Nerve dysfunction from dissection

bull Infection

bull Errors in monitoring

bull Failed attempt Always consider failure as a potential complication

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Arterial Waveform Evaluationbull Tf ndash Foot

ndash Onset of ejectionndash Systole

bull T1 - First Shoulderndash Peak flow

bull T2 - Second Shoulderndash Peak pressure

bull Ti ndash dichotic notchbull End of ejectionbull Closure of aortic valvebull Precedes the onset ofbull diastolebull Tt ndash Pulse Duration

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Arterial Waveform Shapes

bull Rate of upstrokendash Indicates contractility

bull Rate of downstrokendash Indicates peripheral vascular resistance

bull Variations in size during respirationndash Suggest hypovolemia

bull Mean arterial pressurendash Calculated by integrating the area under the

pressure curve

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Arterial Line Tracing

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Waveformsbull Dynamics of pulsatile flowbull Acceleration and

deceleration of bloodbull Elasticity of the arterybull Modulated impedancebull Paradox (aorta1048774distal

arteries) Mean arterial pressure decreases systolic pressure increases

bull Systolic amplification is particularly apparent in noncompliant arteries

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Patient Positioning

bull Radial - Rotate shoulder by 20-30 degrees palm upwards and dorsiflex the wrist (a 500ml intravenous fluid bag makes a useful rest) an assistant or adhesive tape can be used to fix the wrist

bull Femoral - Abduct the leg by 30-40 degrees and externally rotate the hip

bull Brachial - Fully extend the elbow but avoid hyperextension an assistant can help maintain elbow extension

bull Dorsalis Pedis - plantar flex the foot

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Normal Arterial Waveform

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Break Time

10 minutes or so

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Central Line Indications

bull Peripheral venous access is required for ndash Administration of fluidsndash Administration of drugs

bull Central venous access is required for ndash Parenteral nutritionndash Anticipated Inotropic medication infusionndash Anticipated large volume resuscitationndash Monitoring of central venous pressure (CVP)ndash Cardiac pacingndash Difficult peripheral access

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Central Line Contraindications

bull Patient refusal

bull Severe Coagulopathy

bull Bundle Branch Blocks relative contraindication

bull Infection at site

bull Previous failed attempts at specific site

bull Hematoma

bull Unusual anatomy

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Central Line Techniquesbull Sterile techniques should be used for all central line

cannulationbull Surgical scrub with Sterile gown and glovesbull Sterile prep of skin and surgical drapesbull Local anesthetic should be used for central catheters in

awake patientsbull Success may be improved by using ultrasound guidancebull Techniques of gaining access include

ndash Catheter over needlendash Catheter through needlendash Seldinger techniquendash Surgical cut-down is surgical technique as last resort

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Seldinger technique

bull There are four steps to the Seldinger technique

bull Venous puncture is performed with an introducer needle

bull A soft tipped guide wire is passed through the needle and the needle removed

bull A dilator is passed over the guide wire

bull Dilator is removed and catheter is passed over wire and wire is removed

bull Chest x-ray should be performed to check position of catheter

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Anatomy of Central Assess

bull Internal jugular vein ndash Right sided access preferred Whyndash Apical pleura does not rise as high on right and avoids thoracic ductndash Patient positioned head downndash In the low approach triangle formed by two heads of sternomastoid and

clavicle identifiedndash Cannula aimed down and lateral towards ipsilateral nipple

bull Subclavian vein ndash Usually approached from below claviclendash Patient positioned head downndash Needle inserted below junction of medial 23 and lateral 13 of the claviclendash Needle aimed towards suprasternal notchndash Passes immediately behind claviclendash Vein encountered after 4-5 cm

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Normal CVP Waveform

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Waveform Interpretationbull + a wave This wave is due to the increased atrial

pressure during right atrial contraction It correlates with the P wave on an EKG

bull + c wave This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction It correlates with the end of the QRS segment on an EKG

bull - x descent This wave is probably caused by the downward movement of the ventricle during systolic contraction It occurs before the T wave on an EKG

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Waveform Interpretation

bull + v wave This wave arises from the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve It occurs as the T wave is ending on an EKG

bull - y descent This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle It occurs before the P wave on an EKG

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Cannon ldquoArdquo Waves

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

ldquoArdquo Waveform Analysis

bull Cannon Arterial Wavebull Cannon a waves are abnormalities in the a wave that

occur when right atrial contraction takes place against a closed tricuspid valve

bull Classically occurs in 3rd degree heart block or AV dissociation

bull Unlike giant a waves which are uniform in height and are observed during each cardiac cycle cannon a waves are variable in height and occur sporadically because of the variable relationship of atrial contraction to ventricular systole

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Complications Central lines

bull Earlyndash Hemorrhagendash Air embolusndash Pneumothoraxndash Cardiac arrhythmiasndash Pericardial tamponadendash Failed cannulation

bull Latendash Venous thrombosisndash Infection

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Infection Risks For Central Line

bull 10 of central lines become colonized with bacteriabull 2 of patients in ICU develop catheter-related sepsisbull Usually due to coagulase-negative staphylococcus

infectionbull Occasionally due to Candida and Staph aureusbull Infection can be prevented lessened by aseptic

techniques and adequate care of linesbull Closed systems should be used at all timesbull Dedicated lines should be used for parenteral nutritionbull Antimicrobial coating of lines may reduce the risk of

infection

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Break Time

10 minutes or so

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

BIS Monitoring

bull Bispectral Monitoring by Aspect Medical Systems is a non-invasive technology

bull A BIS sensor is placed on your forehead and then connected through a cable to a monitor

bull Together the sensor and monitor measures your brain activity and then computes a number between 0 and 100 which corresponds to your level of consciousness

bull So What you say

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

What is the BIS

bull Through BIS technology we may have a better understanding of the human brain

bull The BIS technology measures the effects of drugs on the brain a previously unknown element of patient status

bull BIS technology is widely studied and widely accepted and is supported by more than 2500 published studies

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

More About the BIS

bull The technology has been used on more than 152 million patients around the world and is utilized in more than 70 of the top-ranked US hospitals (according to a 2005 US News and World Report ranking)

bull Whats the Big Deal

bull It costs about 15 dollars per BIS strip Is it worth it and how does it help me

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Awareness Under Anesthesia

bull Incidence and adverse outcomes of awareness with recall in adults should be part of your post op assessment

bull Research demonstrates that awareness with recall occurs in one to two patients per thousand receiving general anesthesia Historically in trauma and cardiac surgical patients mostly

bull Prospective research shows that approximately 50 of patients that experience awareness with recall suffer psychological problems

bull The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on preventing and managing the impact of anesthesia awareness

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Recent Article NEJM

bull The New England Journal of Medicine published a study that concludes that the Aspect Medical BIS Monitor is no more effective than older products at preventing anesthesia awareness

bull Really does it matter I will say no because of all of the other things the BIS monitor does

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Practice Guidelines

bull The Practice Advisory for Intraoperative Awareness and Brain Function Monitoring published in 2006 describes using multiple monitoring modalities clinical techniques conventional monitoring and brain function monitoring to assess anesthetic depth and reduce the likelihood of intraoperative awareness The Practice Advisory consensus opinion was that the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Bottom Line with the BIS

bull BIS can help clarify the distinction between brain and spinal cord responses enabling you to manage anesthetic goals of hypnosis analgesia and immobility

bull Because BIS measures electrical activity in the brain it provides a direct correlation with depth of consciousness (hypnosis)

bull Responses to surgical stimulation are frequently indicators of the need for additional analgesia These responses are often mediated at the spinal cord What is MAC BAR

bull BIS enables you to assess consciousness and sedation separately from cardiovascular reactivity

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

How it Works

bull Raw EEG information is obtained via a sensor placed on patients forehead currently left or right brain monitoring

bull The BIS system processes the EEG information and calculates a number between 0 and 100 that provides a direct measure of the patients level of consciousness

bull A BIS value near 100 indicates the patient is fully awake I took a BIS reading off of a freshly pronounced body and the BIS reading was 53

bull A BIS value of zero indicates the absence of brain activity

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Drug Savings

bull See References

bull Less drug and less overdosing of anesthesia

bull Sweet

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

Faster Wake Ups

bull BIS-monitored patients wake up faster are extubated sooner and are more oriented upon arrival to the PACU

bull Use of the BIS for wake up is awesome

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

PACU discharge time

bull BIS-monitored patients have been shown to be eligible for PACU discharge 16 sooner

bull I am on retainer at the Aspect Medical Corp Just a little joke

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

References

bull Blitt CD Hines HL Monitoring in Anesthesia and Critical Care Medicine New York Churchill Livingstone 1995

bull Costanzo L Board Review Series Physiology Baltimore Lipincott Williams and Wilkins 1998

bull Miller Anesthesia 5th ed Churchill Livingstone Inc 2000

bull Mikhail M Morgan GE Murray MJ Clinical Anesthesiology third edition New York McGraw Hill 2002

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

References

bull Barish P et al Clinical Anesthesia Third ed Philadelphiabull Lippencott 1997 (626-629)bull Marino D The ICU Book Second ed New York

LippincottWilliams amp Wilkins 1998 (143-153)bull Miller R et al Anesthesia Fourth ed Vol1 New York

Churchill-bull Livingstone 1994 (1166-1169)bull Morgan G et al Clinical Anesthesiology Third ed San

FranciscoLange 2002 (91-97)bull httphemodynamicsucdavisedumustafaPulsehtmbull httpwwwcssolutionsbiz

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

References Conrsquot

bull New England Jounal Of Med ldquoAnesthesia Awareness and the Bispectral Indexrdquo Volume 3581097-1108

bull Sandin R Enlund G Awareness during anesthesia a prospective case study The Lancet 2000 Vol 355

bull Myles P Williams D Patient satisfaction after anaesthesia and surgery results of a prospective survey of 10811 patients British Journal of Anaesthesia 2000 84 (1)

bull Luginbuhl M Schnider TW Detection of awareness with the Bispectral Index two case reports Anesthesiology 2002 96 (1) 241-243

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

More References

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815

bull Mayfield JB Quigley JD BIS monitoring reduces phase I PACU admissions in an ambulatory surgical unit (ASU) Anesthesiology 1999 91 (3A) A28

bull Gan TJ Glass PS Windsor A Payne F Rosow C Sebel P Manberg P and the BIS Utility Study Group Bispectral Index monitoring allows faster emergence and improved recovery from propofol alfentanil and nitrous oxide anesthesia Anesthesiology 1997 87 (4) 808-815