When you see beyond monitor. A very nice lecture tells you Why we do diagnostic errors ..with a plenty of real clinical examples…good resource for all residents in all levels to review the basics of Hemodynamic monitoring…and more…
I spent more than two month preparing this lecture….it is all about anaesthesia residents teaching….
I hope that you will like it
Ahmad M. Abou Leila
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When you read beyond the monitor share version
1. When you see beyond
monitors..
The Diagnosis errors and Diagnosis game
Ahmad Abou Leila
PGY5 –Anesthesiology
American University of Beirut
Ahmad M. Abou Leila
2. Take our monitoring skills to the next level.
1
Integrate the clinical skills with the monitoring
2 skills
Why we do Diagnosis errors?
3
How to avoid the Dx errors
4
Ahmad M. Abou Leila
25. Availability bias
“Dx according to what available
in our Brain
Less available pathology less Dx”
Representativeness Confirmation Bias
“miss the atypical features”
outcome bias
“choosing Dx with good Premature closure
outcomes avoid dx with bad
outcome”
Overconfidence Bias Diagnosis
momentum
Ahmad M. Abou Leila
26. 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
28. Availability bias
We see a lot of hypovolemia …ready
available in our minds
Out come bias
Obese patient ..Lap chole.. Hypovolemia better prognosis than PE
Post operative he developed
tachycardia and hypotension
It is Hypovolemia
Premature closure
JP drain ZERO ..
He was Treated as
hypovolemic Insert A-line and volume administration
(voluven,blood..etc) Confirmation Bias and Dx momentum
Death
Ahmad M. Abou Leila
29. After Spinal anesthesia in asthmatic patient
Patient become Dyspneic and desaturation
The resident explanation
“it is false reading”
Ahmad M. Abou Leila
32. “it is false reading”
premature closure..
Ahmad M. Abou Leila
33. 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
34. Pulmonary embolism
Aspiration
Tocolytic pulmonary edema
Pre-eclampsia Pulmonary edema
Anxiety
Ahmad M. Abou Leila
35. 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
36. To write goo differential list ..you have to answer three questions
Ahmad M. Abou Leila
37. What is the most common cause?
What is the most serious cause?
What is the most likely cause?
Ahmad M. Abou Leila
39. What is the most common Hpovolemia(bleeding)
cause? Epidural anesthesia
Pulmonary embolism
What is the most serious
Mediastinal shift
cause?
What is the most likely cause?
Ahmad M. Abou Leila
48. 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
56. 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
57. 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
67. Aorta
Brachial artery
As you go Further
Pulse amplification
Taller systolic peak
Lower diastolic pressure
Dorsalis pedis
Ahmad M. Abou Leila
68. Measured SBP in In Shock
radial and DP Vasoconstriction
False sense of
Is 20mmHg Peripheral pulse
security
higher than Higher then
central Aorta central
Ahmad M. Abou Leila
69. Systolic pressure monitoring
Reflects Not Change with site Not
blood flow Peripheral augmentation related to autoregulation
initial upstroke
Ahmad M. Abou Leila
70. CPP MAP-ICP
SVR MAP-CVP/CO
coronary Diastolic pressure-LVEDP
Abdomen MAP-IAP
Systolic Blood pressure didn’t appear in autoregulation
Ahmad M. Abou Leila
71. Mean Arterial Blood Pressure
MAP Indicator of blood flow
MAP Main Determinants of autoregulation
Not affected by Reflected waves
MAP
No peripheral augmentation
Not affected by over Damping and
MAP
underdamping
Ahmad M. Abou Leila
72. Lowest MAP without
hypoperfusion
Severe HTN :65
MAP Treated HTN:53
Normal :43
Ahmad M. Abou Leila
107. Oxygen saturation in the central line
ScVO2 is lower SVO2 by
2%-3%
ScVO2 =SVC SVO2=SVC+IVC
SVC sampling Brain consumption is IVC more oxygen
Central line higher than rest of SVO2 more
body…SVC less O2
ScVO2 less
Ahmad M. Abou Leila
109. 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
110. ScVO2 European Multicenter study
73 Critical care 2006,10 R185
Deflaviis et al
ScVO2
>70 Minerva anesthesiology 2006
ScVO2 Pearse et al
75 Critical care 2009,9 R694-699
SVO2 Polonen et al
>70 Anes-Analgesia 2000,90:1052-1059
Ahmad M. Abou Leila
111. 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
119. Tests to assess
recovery
Tests to assess
Depth
Ahmad M. Abou Leila
120. TOF% 30 40 50 60 70 80 90
Head lift
5sec
Tongue
Depressor
test
V or T Fade
TOF detection
V or T
DBS
Fade detection Safe
extubation
50 HZ Fade No
Tetanus detection
residual
100 HZ
paralysis
Fade detect
Tetanus
Always Use quantitative test
Ahmad M. Abou Leila
121. TOF% 30 40 50 60 70 80 90
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 durationAhmad M.
of action. Abou Leila
Anesthesiology 2003;98:1042–8
122. TOF% 30 40 50 60 70 80 90
Safe
extubation
No
residual
paralysis
AhmadReversaltooffour hoursLeilasingle intubating dose
Caldwell JE.
M. residual neuromuscular block with
neostigmine at one Abou after a
of vecuronium. Anesth Analg 1995;80:1168–74
123. Patient A Co-oximetry results
What will be the SPO2
Oxy Hb 70%
reading in these two
Reduced Hb 10 %
Carboxy Hb 20% patients?
Both SPO2= 90
SPO2 reads only oxy and
reduced
And reads the COHB as Oxy
Patient B Co-oximetry results HB
Oxy Hb 50%
Reduced Hb 10 %
Carboxy Hb 40%
Ahmad M. Abou Leila
125. Oxygen saturation Gap
SPO2-SaO2>5
Abnormal Hb not measured by SPO2
Ahmad M. Abou Leila
126. 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