BWH Monitoring Practices

Transcription

1 BWH Monitoring Practices James H. Philip, M.E.(E.), M.D., C.C.E. Anesthesiologist and Director of Bioengineering, Brigham and Women's Hospital Medical Liaison for Anesthesia, Partners Department of Biomedical Engineering Professor of Anaesthesia, Harvard Medical School Distant Past President, Society for Technology in Anesthesia. Copyright , James H Philip, all rights reserved.

2 Quick summary of order of connection SpO2 probe on a finger on IV side; nail symbol over nail NIBP cuff on another extremity; set AUTO to 2.5 min. Don t use START/STOP button. Gets 1 reading only. Patient heating system connected and on ECG Electrodes applied, all 5 There will be minor variations * NBP and NIBP are both noninvasive blood pressure

3 Systems with overlap Monitoring Equipment PM = Physiological Monitor, focused on CV system GE Solar 8000 or B-850 in OR GE Dash or B650 in other BHW locations ADS = Anesthesia Delivery System = Anesthesia Machine + Breathing Circuit Built-in monitor focused on Ventilation and Gases GE Aisys or Draeger Apollo

4 PM = Physiologic Monitor = GE Solar 8000 or B850 What PM Does Pulse oximeter for SpO2 and pulse rate NBP Arterial blood pressure Intravascular Arterial when indic. Other blood pressures CVP, PA, surgical site ECG 5 lead typical for heart rate, rhythm, ischemia detection Display of some variables from ADS monitor Numeric trends Graphic trends

5 ADS Ventilation and Gas Monitor: GE Aisys, Draeger Apollo A Gas composition Oxygen concentration I & E B Carbon dioxide partial pressure I & E Anesthetic Agents in % composition in mmhg in % of 1 atmosphere Gas volumes, flows, pressures Tidal Volume (VT,TV) ml/breath Minute ventilation (MV) L/min Flow Insp up, Exp down Pressure - peak, plateau or pause, mean, end-expiratory cmh2o A We have a few other ADSs, discussed elsewhere B I means mean inspired; E means end-tidal expired

6 Other common monitors Neuromuscular blockade monitor when paralytic drugs are used Monitor isometric contraction Stim ulnar n. - feel thumb adduction, occas. quantitative monitor Stim facial n. - feel jaw closure at chin Brain Monitor when indicated - BIS, PSI Specialty-specific monitors Cerebral O 2, Evoked potentials Venous Compliance Pulse Wave Variation Hb more

7 Physiologic Monitor GE (General Electric) brand is standard throughout Hospital Solar 8000, Dash, BX50 are the models (Generally OK Many hidden features Occasionally problematic Beware of Alarm Silence / Pause

8 Solar 8000Alarm Silence / Pause - OR Mode SILENCE ALARM key functions as follows Press x 1 = 5 minute pause Press x 2 = 15 minute pause Press x 3 = permanent pause Press x 4 = alarms on, again

9 Select NEW CASE Setup for each case Avoids incorrect alarms, intervals, filters, etc. Here s how.

10 More menus

11 Main Menu

12 New Case Setup

13 New Case Setup Monitor waits quietly for next patient Alarms become functional when next patient is connected

14 ECG for OR 5 Leads RA, LA, LL for I, II, III RL as reference lead V5 as lateral V lead RA V5 LA RL LL

15 ECG for PACU 5 Leads RA, LA, LL for I, II, III RL as reference lead V5 as lateral V lead RA RL LA V5 LL Expedient and convenient

16 LEADS DISCONNECTED means, Cable to Connector Block is disconnected Cable is disconnected from monitor Two leads are disconnected somewhere GE PDM (Patient Data Module) can overcome single lead fault Limits the leads you can monitor

17 Trim Knob and Quick Keys

18 NIBP, NBP (noninvasive blood pressure) Don t use Go/Stop quick key to start monitoring Go/Stop measures once and only once!!!!!

19 Press AUTO for NBP Set interval to, 1 min, 2 min, 2.5 min, 5 min NBP Monitoring then starts automatically

20 STAT NBP button Measures NBP as frequently as it can Typically every 20 seconds After 5 minutes reverts to previous Auto Interval Use STAT at times of observed or expected BP change

21 STAT mode NBP displays quick systolic estimate as cuff deflates

22 STAT NBP is q 20 sec for 5 minutes

23 Observe Trends with Quick Keys

24 Select three patient parameters for graphs Not an easy task See separate lecture Solar 8000 Select 3 trend graphs

25 Tabular Trends with one Quick Key

26 Tabular Trends

27 Move between Tabular and Graphic Trends

28 Make other adjustments that are easier

29 SpO2 Averaging Time is 2 seconds

30 SpO2 Averaging Time is 8 seconds in other locations in Hospital 8

31 Gas Monitoring SAM (Smart Anesthesia Multi-Gas) Module Press PUMP to get a head start

32 SAM Module

33 BTW, Exhaust connects elsewhere

34 BTW, Exhaust connects elsewhere Breathing Circuit (Apollo, some Fabius) Scavenger interface and WAGD* system (other Anes Machines)

35 Gas Monitoring SAM (Smart Anesthesia Multigas) Module Press PUMP to get a head start Otherwise, sample gas pump draws 50 ml/min waits to see CO2 misses the first breath or two Then draws 300 ml/min Continuously measures and graphs gases Identifies agent and continuously measures it

36 Gas Monitoring SAM (Smart Anesthesia Multigas) Module Press PUMP to get a head start on monitoring Monitors CO 2 waveform, rate, Insp, Exp (End-Tidal) Oxygen - Insp, Exp (End-Tidal) Nitrous oxide Insp, Exp (End-Tidal) Agents Iso, Sevo, Des Iso and Des are hard to differentiate Absorb similar spectra in IR range Auto defaults = Iso.

37 Gas Display Has trouble differentiating Isoflurane from Desflurane Both have similar Infrared Absorbsion User much choose between them Isoflurane is the default between these two

38 Gas Display Iso

39 Select Des if you will use it and not Iso Des has been targeted for decreased use

40 Choose between Iso & Des

41 Trim Knob and Quick Keys to Choose Gas

42 Lots of adjustments Learn them Use them Be careful Admit New Patient to return to BWH OR Defaults

43 Don t adjust ECG Filter unless you have a real need for it

44 Select ECG ECG Filter can be set Filter window should be set to Moderate; never to maximum

45 Monitoring Maximum Filter There is major degradation with Maximum Filtering

46 } Filter Choices MODERATE DIAGNOSTIC.05Hz to 100Hz - Least filtering. Good for all but myocardial contusion which needs still higher upper end MONITORING.05Hz to 40Hz - Typical monitoring; BWH OR and ICU Default Eliminates 60 Hz (50 Hz UK) power line artifacts. Retains low frequency signal MODERATE.05Hz to 25Hz - Reduces high frequency interference, Including Power Line, ESU, EMG, patient movement MAXIMUM 5Hz to 25Hz - Maximum filtering. Stabilizes ECG baseline. Distorts information in S-T and T waves ST analysis still is correct. It uses Diagnostic

47 GE Idiosyncrasies Sevo MAC and MAC Fraction are wrong MAC = 1.7% but should be 2.1% All other monitors are correct

48 GE Idiosyncrasies Sevo MAC and MAC Fraction are wrong MAC = 1.7% but should be 2.1% After 96 NBPs, the 97th throws away the first NBP cannot be displayed on 6 minute trend graph Web lecture shows some additional pictures

49 Anything wrong here?

50 Anything wrong here? Sevo MAC Fraction is wrong

51 Sevo MAC is wrong

52 96 NBP max 97th NBP throws away the first one

53 96 NBP max 97th NBP throws away the first one

54 Our Monitors and their history 1994 Marquette Solar 8000 Monitor Tram-rac Modular remote acquisition case 1996 Marquette Eagle compact monitor 1998 Marquette Medical Systems sold to GE 2001 GE Dash monitor replaced Eagle year old design Not compatible with ecare and Epic Parts no longer available No new sales GE has a new product line Carescape B450 (floor), B650 (PACU w CO2), B850 (OR w everything)

55 GE Carescape B850 Monitor components 19 Display Modules (usual + qnmt BIS/Entropy + more Processing Unit PDM - Patient Data Module Module Frame F5

56 PDM - Patient Data Module collects, processes, stores q 1 minute data for 24 hours, or, until I Admit Next Patient Limit 96 NBP readings

57 emodules measure much more BIS or Entropy, quantitative NMT, many more

58 Standard On / Off Controls that meet International Electrotechnical Commission AKA, IEC On/Off Symbols 1 = on, 0 = off Full On power Full Off power Toggle Full On / Full Off power Toggle Full On / Partial Off or Soft Off or Standby

59 Use On / soft Off Switch

60 Don t turn off Hard power switch Processing Unit

61 Don t turn off Hard power switch to Display

62 SuperUsers were trained and we started using B850 on 3/4/14 Limited number of monitored in limited areas Many limitations of Solar 8000 are corrected Menus require thought and then become intuitive

63 Learn More Anes Department Intranet Site (Anes Dept only) Education Anesthesia Technology Educational content can be reached from outside Partners

64 Thank you