When you see beyond

monitors.. The Diagnosis errors and Diagnosis game

Ahmad Abou Leila

PGY5 –Anesthesiology

American University of Beirut

Ahmad M. Abou Leila

Take our monitoring skills to the next level.

Integrate the clinical skills with the monitoring skills

Why we do Diagnosis errors?

1

2

3

4 How to avoid the Dx errors

Ahmad M. Abou Leila

Making Diagnosis errors

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Common Ahmad M. Abou Leila

Common Ahmad M. Abou Leila

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Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Cognitive Errors

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Ahmad M. Abou Leila

Perception errors Ahmad M. Abou Leila

When you separate patients from the monitor

Ahmad M. Abou Leila

BP100/52 72 y/o

(Hypotension)

20y/o (normal)

Numbers are meaningless without patients

Ahmad M. Abou Leila

VPB

Renal failure Massive transfusion, SUX in Bed ridden

Check the electrolytes and management

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VPB

Healthy patients during left lobectomy

Cautery irritation

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Patient A PaCO2=40

Discharged to floor

Patient B PaCO2=40

Respiratory Acidosis

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Patient B: pregnant woman After 38 weeks PaCO2 <30

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Regular craniotomy Pituitary surgery TBI

Mannitol Therapy Diabetes insipidus Cerebral salt wasting

Ahmad M. Abou Leila

Mannitol Therapy Diabetes insipidus Cerebral salt wasting

Normal Na Hypernatremia Hponatermia

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Positive test Dose

Healthy surgical patients

HR > 20BPM BP >15 mmHg

T wave amplitude decrease

Ahmad M. Abou Leila

Processing Errors Ahmad M. Abou Leila

Representativeness “miss the atypical features”

Availability bias “Dx according to what available

in our Brain Less available pathology less Dx”

outcome bias “choosing Dx with good

outcomes avoid dx with bad outcome”

Overconfidence Bias

Premature closure

Confirmation Bias

Diagnosis momentum

Ahmad M. Abou Leila

Obese patient ..Lap chole..

Post operative he developed tachycardia and hypotension

JP drain ZERO ..

He was Treated as hypovolemic (voluven,blood,Aline)

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Obese patient ..Lap chole..

Post operative he developed tachycardia and hypotension

JP drain ZERO ..

He was Treated as hypovolemic

(voluven,blood..etc)

Availability bias We see a lot of hypovolemia …ready

available in our minds

Out come bias Hypovolemia better prognosis than PE

It is Hypovolemia Premature closure

Insert A-line and volume administration Confirmation Bias and Dx momentum

Death Ahmad M. Abou Leila

After Spinal anesthesia in asthmatic patient

Patient become Dyspneic and desaturation

The resident explanation

“it is false reading”

Ahmad M. Abou Leila

Patient Turned Blue…and again …

Ahmad M. Abou Leila

Ahmad M. Abou Leila

“it is false reading”

premature closure..

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38 y/o female patient Preclampsia… C/S under GA… Everything is fine

Post Operative she developed severe Dyspnea

What is your differential ?

Ahmad M. Abou Leila

Pulmonary embolism Aspiration

Tocolytic pulmonary edema Pre-eclampsia Pulmonary edema

Anxiety

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Not every Postoperative Nausea…..Do EGK to rule out MI

Never get the habit of MED student after Brugada lesson

Every ST elevation has to rule out brugada

Base-rate neglect Bias

the tendency to ignore the true prevalence of a disease

Tendency to Diagnose “exotic “ things

Ahmad M. Abou Leila

To write goo differential list ..you have to answer three questions

Ahmad M. Abou Leila

What is the most common cause?

What is the most serious cause?

What is the most likely cause?

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Ahmad M. Abou Leila

What is the most common cause?

What is the most serious cause?

What is the most likely cause?

Hpovolemia(bleeding) Epidural anesthesia

Pulmonary embolism Mediastinal shift

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Clamp the Drain……. allow the air to fill the cavity call for Surgeon

Mediastinal shift

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56 y/o female patient osteoperosis,otherwise healthy…

Kyphoplasty…interventional radiology..LA+sedation PACU Dyspnea

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Pulmonary cement embolism After vertebroplasty Ahmad M. Abou Leila

Ahmad M. Abou Leila

What is the most common cause?

What is the most serious cause?

What is the most likely cause?

Opioid overdose

Pontine hge

Ahmad M. Abou Leila

Most likely ..organopphosprous poisoning

SUXMETHONIUM is CI

Ahmad M. Abou Leila

During transfer of TOF baby after DX cardiac CATH

Baby become cyanotic and saturation dropped to 60

Baby had normal breathing pattern(no labored breathing or obstruction)

Ahmad M. Abou Leila

Ahmad M. Abou Leila

I gave the baby oxygen..but he still blue

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Least likely cause of this desaturation

Most likely cause of cynosis (TET spells)

Ahmad M. Abou Leila

Photo from the BLOG

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

After CSE for Multigravida patient the OB resident informed you that

there is significant FHR abnormalities …..

What you think ?

Patient Placed Right side up and BP

normal…

Still FHR abnormal

What you think ? Rule out Uterine Hypertonus

Ahmad M. Abou Leila

Logistic regression analysis showed the type of analgesia as the only independent predictor of uterine hypertonus (odds ratio 3.526, 95% confidence interval 1.21-10.36; P=.022).

Combined spinal-epidural analgesia is associated with a significantly greater incidence of FHR abnormalities related to uterine hypertonus compared with epidural analgesia

Ahmad M. Abou Leila

Deficient Knowledge Ahmad M. Abou Leila

When heart Pumps Blood into the vessels

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Vascular system is not straight line …..

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Vascular system is highly branched system. .with many branches and bifurcations

Ahmad M. Abou Leila

Ahmad M. Abou Leila

A-line tracing in elderly

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A-line tracing in young

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Appear during Vasoconstriction

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Combination of two waves… Higher wave amplitude

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Aorta

Brachial artery

Dorsalis pedis

As you go Further Pulse amplification Taller systolic peak

Lower diastolic pressure

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Measured SBP in radial and DP Is 20mmHg higher than

central Aorta

In Shock Vasoconstriction Peripheral pulse

Higher then central

False sense of security

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Reflects

initial upstroke

Not

blood flow

Change with site

Peripheral augmentation

Not

related to autoregulation

Systolic pressure monitoring

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MAP-ICP CPP

MAP-CVP/CO SVR

Diastolic pressure-LVEDP coronary

MAP-IAP Abdomen

Systolic Blood pressure didn’t appear in autoregulation

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Indicator of blood flow MAP

Not affected by Reflected waves

No peripheral augmentation MAP

Main Determinants of autoregulation MAP

Not affected by over Damping and

underdamping MAP

Mean Arterial Blood Pressure

Ahmad M. Abou Leila

Lowest MAP without hypoperfusion

MAP Severe HTN :65 Treated HTN:53

Normal :43

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Better Together Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

bisferiens pulse

initial peak upstroke from rapid left ventricular ejection in early systole

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Pulsus alternan…..Not related to MV

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Severe vasoconstriction

Elevated DP

Multiple RW

Slow up rise of systolic pressure

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Severe AR HOCM IABP Severe AS and Severe

AR

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

In Aline leveling is not a problem but in CVP is CVP is very small number

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Accurate Zeroing

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Accurate Zeroing

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Injection of cold saline 1

2

Measure the Temperature change

Entrance of cold saline

3

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

U will not see the regular atrial Pressure wave in the severe tricuspid regurge U will have VENTRICULIZATION of ATRIA

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Ahmad M. Abou Leila

SVO2=SaO2-(VO2/COx1.36xHct) X 100

Ahmad M. Abou Leila

Venous oximetry

Reduced venous oxygen saturation better predicts adverse outcome after cardiac surgery than does

cardiac output

Venous oximetry detects organs hypoperfusion (VO2)before organs

ischemia develop

Ahmad M. Abou Leila

It is toooooooooooooooooo complicated Any thing else instead

Ahmad M. Abou Leila

Oxygen saturation in the central line

SVC sampling Central line

ScVO2 is lower SVO2 by 2%-3%

ScVO2 =SVC Brain consumption is

higher than rest of body…SVC less O2

ScVO2 less

SVO2=SVC+IVC IVC more oxygen

SVO2 more

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Current evidence and consensus-based guideline for monitoring and treatment of cardiac surgery patients during the postoperative period in

ICU recommends an ScvO2 > 70% SvO2 > 65%

Ahmad M. Abou Leila

European Multicenter study Critical care 2006,10 R185

Deflaviis et al Minerva anesthesiology 2006

Pearse et al Critical care 2009,9 R694-699

ScVO273

ScVO2 >70

ScVO275

SVO2>70

Polonen et al Anes-Analgesia 2000,90:1052-1059

Ahmad M. Abou Leila

Why venous oximetry?

60% of patient udergoing major surgeries develop intestinal ischemia

SVO2 or ScVO2 directed therapy associated with less postoperative complications and mortality

Small increase with SVO2 associated with significant decrease in the mortality

Ahmad M. Abou Leila

ACT monitoring

Ahmad M. Abou Leila

Ahmad M. Abou Leila

ACT contact activator

Celite

Kaolin

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Aprotonin inhibit

Celite

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Prolonged ACT Sub optimal heparin

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Kaolin containing should be used

Ahmad M. Abou Leila

Muscle relaxants monitoring

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Tests to assess

recovery

Tests to assess

Depth

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30 40 50 60 70 80 90 TOF%

Safe extubation

No residual paralysis

Head lift 5sec

Tongue Depressor

test

V or T TOF

Fade detection

V or T DBS

Fade detection

50 HZ Tetanus

Fade detection

100 HZ Tetanus

Fade detect

Always Use quantitative test

Ahmad M. Abou Leila

30 40 50 60 70 80 90 TOF%

Safe extubation

No residual paralysis

Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003;98:1042–8

Ahmad M. Abou Leila

30 40 50 60 70 80 90 TOF%

Safe extubation

No residual paralysis

Caldwell JE. Reversal of residual neuromuscular block with neostigmine at one to four hours after a single intubating dose of vecuronium. Anesth Analg 1995;80:1168–74

Ahmad M. Abou Leila

Patient A Co-oximetry results Oxy Hb 70% Reduced Hb 10 % Carboxy Hb 20%

Patient B Co-oximetry results Oxy Hb 50% Reduced Hb 10 % Carboxy Hb 40%

What will be the SPO2 reading in these two

patients? Both SPO2= 90

SPO2 reads only oxy and reduced

And reads the COHB as Oxy HB

Ahmad M. Abou Leila

Oxygen saturation Gap SPO2-SaO2

OSG<5

Ahmad M. Abou Leila

Oxygen saturation Gap SPO2-SaO2>5

Abnormal Hb not measured by SPO2

Ahmad M. Abou Leila

Link the monitor data to the patient physiology…number alone are meaningless Before you make your diagnoses ASK your self” what else might this be?” what did I miss” Remember the three questions “the Most common” ”The most dangerous” and the most likely” Don’t be overconfident…ask for feedback The most important ting to improve your Diagnosing skills is Read and practice

Ahmad M. Abou Leila

Ahmad M. Abou Leila

Have a nice day

Ahmad M. Abou Leila