When you read beyond the monitor share version

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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. 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. 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
  3. 3. Making Diagnosis errors Ahmad M. Abou Leila
  4. 4. Common Ahmad M. Abou Leila
  5. 5. Common Ahmad M. Abou Leila
  6. 6. Ahmad M. Abou Leila
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  10. 10. Cognitive Errors Ahmad M. Abou Leila
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  12. 12. Perception errors Ahmad M. Abou Leila
  13. 13. When you separate patients from the monitor Ahmad M. Abou Leila
  14. 14. Numbers are meaningless without patients 72 y/o 20y/o BP100/52 (Hypotension) (normal) Ahmad M. Abou Leila
  15. 15. VPBRenal failureMassive transfusion,SUX in Bed ridden Check the electrolytes and management Ahmad M. Abou Leila
  16. 16. VPBHealthy patients during left lobectomy Cautery irritation Ahmad M. Abou Leila
  17. 17. Patient A Patient B PaCO2=40 PaCO2=40Discharged to floor Respiratory Acidosis Ahmad M. Abou Leila
  18. 18. Patient B:pregnant womanAfter 38 weeksPaCO2 <30 Ahmad M. Abou Leila
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  20. 20. Regular craniotomy Pituitary surgery TBI Mannitol Therapy Diabetes insipidus Cerebral salt wasting Ahmad M. Abou Leila
  21. 21. Normal Na Hypernatremia HponatermiaMannitol Therapy Diabetes insipidus Cerebral salt wasting Ahmad M. Abou Leila
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  23. 23. Positive test Dose Healthy surgical patients HR > 20BPM BP >15 mmHgT wave amplitude decrease Ahmad M. Abou Leila
  24. 24. Processing Errors Ahmad M. Abou Leila
  25. 25. Availability bias “Dx according to what available in our BrainLess 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. 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
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  28. 28. Availability bias We see a lot of hypovolemia …ready available in our minds Out come biasObese patient ..Lap chole.. Hypovolemia better prognosis than PEPost operative he developedtachycardia 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. 29. After Spinal anesthesia in asthmatic patientPatient become Dyspneic and desaturation The resident explanation “it is false reading” Ahmad M. Abou Leila
  30. 30. Patient Turned Blue…and again … Ahmad M. Abou Leila
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  32. 32. “it is false reading”premature closure.. Ahmad M. Abou Leila
  33. 33. 38 y/o female patient Preclampsia… C/S under GA… Everything is finePost Operative she developed severe Dyspnea What is your differential ? Ahmad M. Abou Leila
  34. 34. Pulmonary embolism Aspiration Tocolytic pulmonary edemaPre-eclampsia Pulmonary edema Anxiety Ahmad M. Abou Leila
  35. 35. Not every Postoperative Nausea…..Do EGK to rule out MINever 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. 36. To write goo differential list ..you have to answer three questions Ahmad M. Abou Leila
  37. 37. What is the most common cause?What is the most serious cause? What is the most likely cause? Ahmad M. Abou Leila
  38. 38. Ahmad M. Abou Leila
  39. 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
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  41. 41. Mediastinal shiftClamp the Drain…….allow the air to fill the cavitycall for Surgeon Ahmad M. Abou Leila
  42. 42. 56 y/o female patient osteoperosis,otherwise healthy… Kyphoplasty…interventional radiology..LA+sedation PACU DyspneaAhmad M. Abou Leila
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  44. 44. Pulmonary cement embolism After vertebroplasty Ahmad M. Abou Leila
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  46. 46. What is the most common Opioid overdose cause? What is the most serious Pontine hge cause? What is the most likely cause? Ahmad M. Abou Leila
  47. 47. Most likely ..organopphosprous poisoning SUXMETHONIUM is CI Ahmad M. Abou Leila
  48. 48. During transfer of TOF baby after DX cardiac CATH Baby become cyanotic and saturation dropped to 60Baby had normal breathing pattern(no labored breathing or obstruction) Ahmad M. Abou Leila
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  50. 50. I gave the baby oxygen..but he still blue Ahmad M. Abou Leila
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  52. 52. Least likely cause of this desaturation Most likely cause of cynosis (TET spells) Ahmad M. Abou Leila
  53. 53. Photo from the BLOG Ahmad M. Abou Leila
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  56. 56. After CSE for Multigravida patientthe 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. 57. Logistic regression analysis showed the type of analgesiaas the only independent predictor of uterine hypertonus(odds ratio 3.526, 95% confidence interval 1.21-10.36; P=.022).Combined spinal-epidural analgesiais associated with a significantly greater incidence of FHR abnormalities related to uterine hypertonus compared with epidural analgesia Ahmad M. Abou Leila
  58. 58. Deficient Knowledge Ahmad M. Abou Leila
  59. 59. When heart Pumps Blood into the vessels Ahmad M. Abou Leila
  60. 60. Vascular system is not straight line ….. Ahmad M. Abou Leila
  61. 61. Vascular system is highly branched system. .with many branches and bifurcations Ahmad M. Abou Leila
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  63. 63. A-line tracing in elderly Ahmad M. Abou Leila
  64. 64. A-line tracing in young Ahmad M. Abou Leila
  65. 65. Appear during Vasoconstriction Ahmad M. Abou Leila
  66. 66. Combination of two waves…Higher wave amplitude Ahmad M. Abou Leila
  67. 67. Aorta Brachial artery As you go Further Pulse amplification Taller systolic peakLower diastolic pressure Dorsalis pedis Ahmad M. Abou Leila
  68. 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. 69. Systolic pressure monitoring Reflects Not Change with site Not blood flow Peripheral augmentation related to autoregulationinitial upstroke Ahmad M. Abou Leila
  70. 70. CPP MAP-ICP SVR MAP-CVP/COcoronary Diastolic pressure-LVEDPAbdomen MAP-IAP Systolic Blood pressure didn’t appear in autoregulation Ahmad M. Abou Leila
  71. 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. 72. Lowest MAP without hypoperfusion Severe HTN :65MAP Treated HTN:53 Normal :43 Ahmad M. Abou Leila
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  74. 74. Better Together Ahmad M. Abou Leila
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  78. 78. bisferiens pulse initial peak upstroke from rapid left ventricular ejection in early systoleAhmad M. Abou Leila
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  81. 81. Pulsus alternan…..Not related to MV Ahmad M. Abou Leila
  82. 82. Severe vasoconstriction Elevated DP Multiple RWSlow up rise of systolic pressure Ahmad M. Abou Leila
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  85. 85. Severe AS and SevereSevere AR HOCM IABP AR Ahmad M. Abou Leila
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  88. 88. In Aline leveling is not a problem but in CVP is CVP is very small number Ahmad M. Abou Leila
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  90. 90. Accurate Zeroing Ahmad M. Abou Leila
  91. 91. Accurate Zeroing Ahmad M. Abou Leila
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  93. 93. 1Injection of cold saline Measure the 3 Temperature change Entrance of cold saline 2 Ahmad M. Abou Leila
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  101. 101. U will not see the regular atrial Pressure wave in the severe tricuspid regurgeU will have VENTRICULIZATION of ATRIA Ahmad M. Abou Leila
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  104. 104. SVO2=SaO2-(VO2/COx1.36xHct) X 100 Ahmad M. Abou Leila
  105. 105. Venous oximetry Venous oximetry detects organshypoperfusion (VO2)before organs ischemia develop Reduced venous oxygen saturation better predicts adverse outcome after cardiac surgery than does cardiac output Ahmad M. Abou Leila
  106. 106. It is toooooooooooooooooo complicatedAny thing else instead Ahmad M. Abou Leila
  107. 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
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  109. 109. Current evidence and consensus-based guideline for monitoring andtreatment of cardiac surgery patients during the postoperative period in ICU recommends an ScvO2 > 70% SvO2 > 65% Ahmad M. Abou Leila
  110. 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. 111. Why venous oximetry?60% of patient udergoing major surgeriesdevelop intestinal ischemiaSVO2 or ScVO2 directed therapy associatedwith less postoperative complications andmortalitySmall increase with SVO2 associated withsignificant decrease in the mortality Ahmad M. Abou Leila
  112. 112. ACT monitoring Ahmad M. Abou Leila
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  114. 114. ACT contact activatorCeliteKaolin Ahmad M. Abou Leila
  115. 115. Aprotonin inhibitCelite Ahmad M. Abou Leila
  116. 116. Prolonged ACTSub optimal heparin Ahmad M. Abou Leila
  117. 117. Kaolin containing should be used Ahmad M. Abou Leila
  118. 118. Muscle relaxants monitoring Ahmad M. Abou Leila
  119. 119. Tests to assess recovery Tests to assess Depth Ahmad M. Abou Leila
  120. 120. TOF% 30 40 50 60 70 80 90Head lift 5sec TongueDepressor 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. 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. 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. 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 HBOxy Hb 50%Reduced Hb 10 %Carboxy Hb 40% Ahmad M. Abou Leila
  124. 124. Oxygen saturation Gap SPO2-SaO2 OSG<5 Ahmad M. Abou Leila
  125. 125. Oxygen saturation Gap SPO2-SaO2>5Abnormal Hb not measured by SPO2 Ahmad M. Abou Leila
  126. 126. Link the monitor data to the patient physiology…number alone are meaninglessBefore 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 feedbackThe most important ting to improve your Diagnosing skills isRead and practice Ahmad M. Abou Leila
  127. 127. Ahmad M. Abou Leila
  128. 128. Have a nice dayAhmad M. Abou Leila

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