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 1989 - 2015, James H Philip, all rights reserved.

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”

Monitoring Equipment Systems with overlap 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

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

ADS Ventilation and Gas Monitor: GE Aisys, Draeger Apollo A

Gas composition Oxygen concentration I & E B in % composition Carbon dioxide partial pressure I & E in mmHg Anesthetic Agents 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

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 O2, Evoked potentials Venous Compliance Pulse Wave Variation Hb more

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

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

Select NEW CASE Setup for each case

Avoids incorrect alarms, intervals, filters, etc. Here’s how.

More menus

Main Menu

New Case Setup

New Case Setup

Monitor waits quietly for next patient Alarms become functional when next patient is connected

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

RA LA

LL RL

V5

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

RA LA

LL RL V5

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

Trim Knob and Quick Keys

NIBP, NBP (noninvasive blood pressure)

Don’t use Go/Stop quick key to start monitoring Go/Stop measures once and only once

!!!!!

Press AUTO for NBP

Set interval to, 1 min, 2 min, 2.5 min, 5 min NBP Monitoring then starts automatically

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

STAT mode NBP displays “quick systolic” estimate as cuff deflates

STAT NBP is q 20 sec for 5 minutes

Observe Trends with Quick Keys

Select three patient parameters for graphs

Not an easy task See separate lecture – Solar 8000 Select 3 trend graphs

Tabular Trends with one Quick Key

Tabular Trends

Move between Tabular and Graphic Trends

Make other adjustments that are easier

SpO2 Averaging Time is 2 seconds

SpO2 Averaging Time is 8 seconds in other locations in Hospital

8

Gas Monitoring

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

SAM Module

BTW, Exhaust connects elsewhere

BTW, Exhaust connects elsewhere

Breathing Circuit (Apollo, some Fabius) Scavenger interface and WAGD* system (other Anes Machines)

Gas Monitoring

SAM (Smart Anesthesia 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

Gas Monitoring

SAM (Smart Anesthesia Multigas) Module Press PUMP to get a head start on monitoring Monitors

CO2 – 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.

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

Gas Display Iso

Select Des if you will use it and not Iso

Des has been targeted for decreased use

Choose between Iso & Des

Trim Knob and Quick Keys to Choose Gas

Lots of adjustments

Learn them Use them Be careful Admit New Patient

to return to BWH OR Defaults

Don’t adjust ECG Filter unless you have a real need for it

ECG Filter can be set

Select ECG

Filter window should be set to Moderate; never to maximum

There is major degradation with Maximum Filtering

Monitoring Maximum Filter

Filter Choices

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

} MODERATE

ST analysis still is correct. It uses Diagnostic

GE Idiosyncrasies

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

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

Anything wrong here?

Anything wrong here? Sevo MAC Fraction is wrong

Sevo MAC is wrong

96 NBP max 97th NBP throws away the first one

96 NBP max

97th NBP throws away the first one

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

2014 20 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)

GE Carescape B850 Monitor components

19” Display

PDM - Patient Data Module Processing Unit Module Frame F5

Modules (usual + qNMT

BIS/Entropy + more

1 2 3 4 5

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

eModules measure much more

BIS or Entropy, quantitative NMT,

many more

Standard On / Off Controls that meet International Electrotechnical Commission 60417

AKA, IEC 407 1973 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

Use On / soft Off Switch

Don’t turn off “Hard” power switch Processing Unit

Don’t turn off “Hard” power switch to Display

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

Learn More

Anes Department Intranet Site (Anes Dept only) http://bwhanesthesia.org/education/technology

http://bwhanesthesia.org Education Anesthesia Technology Educational content can be reached from outside Partners

Thank you