When you see beyond     monitors..The Diagnosis errors and Diagnosis game            Ahmad Abou Leila         PGY5 –Anesth...
Take our monitoring skills to the next level.1           Integrate the clinical skills with the monitoring    2      skill...
Making Diagnosis errors                          Ahmad M. Abou Leila
Common Ahmad M. Abou Leila
Common  Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Cognitive Errors            Ahmad M. Abou Leila
Ahmad M. Abou Leila
Perception errors                    Ahmad M. Abou Leila
When you separate patients from the monitor              Ahmad M. Abou Leila
Numbers are meaningless without patients                                     72 y/o              20y/o         BP100/52   ...
VPBRenal failureMassive transfusion,SUX in Bed ridden   Check the electrolytes and management                   Ahmad M. A...
VPBHealthy patients during left lobectomy         Cautery irritation                 Ahmad M. Abou Leila
Patient A                                   Patient B    PaCO2=40                                    PaCO2=40Discharged to...
Patient B:pregnant womanAfter 38 weeksPaCO2 <30                 Ahmad M. Abou Leila
Ahmad M. Abou Leila
Regular craniotomy    Pituitary surgery                  TBI   Mannitol Therapy    Diabetes insipidus         Cerebral sal...
Normal Na          Hypernatremia                HponatermiaMannitol Therapy   Diabetes insipidus         Cerebral salt was...
Ahmad M. Abou Leila
Positive test Dose Healthy surgical     patients   HR > 20BPM  BP >15 mmHgT wave amplitude    decrease                    ...
Processing Errors     Ahmad M. Abou Leila
Availability bias “Dx according to what available           in our BrainLess available pathology less Dx”     Representati...
Obese patient ..Lap chole..Post operative he developed tachycardia and hypotension                   JP drain ZERO ..     ...
Ahmad M. Abou Leila
Availability bias                                                    We see a lot of hypovolemia …ready                   ...
After Spinal anesthesia in asthmatic patientPatient become Dyspneic and desaturation        The resident explanation      ...
Patient Turned Blue…and again …        Ahmad M. Abou Leila
Ahmad M. Abou Leila
“it is false reading”premature closure..      Ahmad M. Abou Leila
38 y/o female patient     Preclampsia…     C/S under GA…     Everything is finePost Operative she developed severe Dyspnea...
Pulmonary embolism           Aspiration  Tocolytic pulmonary edemaPre-eclampsia Pulmonary edema             Anxiety       ...
Not every Postoperative Nausea…..Do EGK to rule out MINever get the habit of MED student after Brugada lesson      Every S...
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?      Ahmad M. Abou Leila
Ahmad M. Abou Leila
What is the most common                  Hpovolemia(bleeding)          cause?                          Epidural anesthesia...
Ahmad M. Abou Leila
Mediastinal shiftClamp the Drain…….allow the air to fill the cavitycall for Surgeon                                   Ahma...
56 y/o female patient osteoperosis,otherwise                        healthy…    Kyphoplasty…interventional radiology..LA+s...
Ahmad M. Abou Leila
Pulmonary cement embolism After vertebroplasty               Ahmad M. Abou Leila
Ahmad M. Abou Leila
What is the most common                                              Opioid overdose          cause? What is the most seri...
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 60Baby had...
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)                           ...
Photo from the BLOG                      Ahmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
After CSE for Multigravida patientthe OB resident informed you that      there is significant FHR        abnormalities ….....
Logistic regression analysis showed the type of analgesiaas the only independent predictor of uterine hypertonus(odds rati...
Deficient Knowledge                      Ahmad M. Abou Leila
When heart Pumps Blood into the vessels                                     Ahmad M. Abou Leila
Vascular system is not straight line …..                                 Ahmad M. Abou Leila
Vascular system is highly branched system. .with many branches and bifurcations                                 Ahmad M. A...
Ahmad M. Abou Leila
A-line tracing in elderly                   Ahmad M. Abou Leila
A-line tracing in young                  Ahmad M. Abou Leila
Appear during Vasoconstriction                                 Ahmad M. Abou Leila
Combination of two waves…Higher wave amplitude                Ahmad M. Abou Leila
Aorta                                             Brachial artery   As you go Further  Pulse amplification  Taller systoli...
Measured SBP in       In Shock radial and DP    Vasoconstriction                                             False sense o...
Systolic pressure monitoring    Reflects            Not               Change with site                 Not                ...
CPP                MAP-ICP SVR               MAP-CVP/COcoronary        Diastolic pressure-LVEDPAbdomen             MAP-IAP...
Mean Arterial Blood Pressure           MAP   Indicator of blood flow           MAP   Main Determinants of autoregulation  ...
Lowest MAP without                          hypoperfusion                            Severe HTN :65MAP                    ...
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 systoleAhmad M. Abou Leila
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Pulsus alternan…..Not related to MV          Ahmad M. Abou Leila
Severe vasoconstriction          Elevated DP          Multiple RWSlow up rise of systolic pressure            Ahmad M. Abo...
Ahmad M. Abou Leila
Ahmad M. Abou Leila
Severe AS and SevereSevere AR   HOCM                         IABP                                                         ...
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  Ahmad M. Abou Leila
Accurate Zeroing  Ahmad M. Abou Leila
Ahmad M. Abou Leila
1Injection of cold saline                                                                 Measure the                     ...
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 regurgeU will have VENTRICULIZATION of ATRIA      ...
Ahmad M. Abou Leila
Ahmad M. Abou Leila
SVO2=SaO2-(VO2/COx1.36xHct) X 100            Ahmad M. Abou Leila
Venous oximetry Venous oximetry detects organshypoperfusion (VO2)before organs       ischemia develop  Reduced venous oxyg...
It is toooooooooooooooooo complicatedAny thing else instead           Ahmad M. Abou Leila
Oxygen saturation in the central line                    ScVO2 is lower SVO2 by                            2%-3%          ...
Ahmad M. Abou Leila
Current evidence and consensus-based guideline for monitoring andtreatment of cardiac surgery patients during the postoper...
ScVO2    European Multicenter study  73     Critical care 2006,10 R185                  Deflaviis et al        ScVO2      ...
Why venous oximetry?60% of patient udergoing major surgeriesdevelop intestinal ischemiaSVO2 or ScVO2 directed therapy asso...
ACT monitoring             Ahmad M. Abou Leila
Ahmad M. Abou Leila
ACT contact activatorCeliteKaolin            Ahmad M. Abou Leila
Aprotonin inhibitCelite            Ahmad M. Abou Leila
Prolonged ACTSub optimal heparin          Ahmad M. Abou Leila
Kaolin containing should be used                 Ahmad M. Abou Leila
Muscle relaxants monitoring          Ahmad M. Abou Leila
Tests to assess   recovery    Tests to assess        Depth                      Ahmad M. Abou Leila
TOF%        30           40            50              60         70     80   90Head lift 5sec TongueDepressor   test  V o...
TOF%   30   40                         50                     60                  70     80   90                          ...
TOF%   30   40   50        60                         70                       80   90                                    ...
Patient A Co-oximetry results                                                       What will be the SPO2 Oxy Hb     70%  ...
Oxygen saturation Gap     SPO2-SaO2       OSG<5           Ahmad M. Abou Leila
Oxygen saturation Gap          SPO2-SaO2>5Abnormal Hb not measured by SPO2                Ahmad M. Abou Leila
Link the monitor data to the patient physiology…number alone are meaninglessBefore you make your diagnoses ASK your self” ...
Ahmad M. Abou Leila
Have a nice dayAhmad M. Abou Leila
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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
  7. 7. Ahmad M. Abou Leila
  8. 8. Ahmad M. Abou Leila
  9. 9. Ahmad M. Abou Leila
  10. 10. Cognitive Errors Ahmad M. Abou Leila
  11. 11. Ahmad M. Abou Leila
  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
  19. 19. Ahmad M. Abou Leila
  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
  22. 22. Ahmad M. Abou Leila
  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
  27. 27. Ahmad M. Abou Leila
  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
  31. 31. Ahmad M. Abou Leila
  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
  40. 40. Ahmad M. Abou Leila
  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
  43. 43. Ahmad M. Abou Leila
  44. 44. Pulmonary cement embolism After vertebroplasty Ahmad M. Abou Leila
  45. 45. Ahmad M. Abou Leila
  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
  49. 49. Ahmad M. Abou Leila
  50. 50. I gave the baby oxygen..but he still blue Ahmad M. Abou Leila
  51. 51. Ahmad M. Abou Leila
  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
  54. 54. Ahmad M. Abou Leila
  55. 55. Ahmad M. Abou Leila
  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
  62. 62. Ahmad M. Abou Leila
  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
  73. 73. Ahmad M. Abou Leila
  74. 74. Better Together Ahmad M. Abou Leila
  75. 75. Ahmad M. Abou Leila
  76. 76. Ahmad M. Abou Leila
  77. 77. Ahmad M. Abou Leila
  78. 78. bisferiens pulse initial peak upstroke from rapid left ventricular ejection in early systoleAhmad M. Abou Leila
  79. 79. Ahmad M. Abou Leila
  80. 80. Ahmad M. Abou Leila
  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
  83. 83. Ahmad M. Abou Leila
  84. 84. Ahmad M. Abou Leila
  85. 85. Severe AS and SevereSevere AR HOCM IABP AR Ahmad M. Abou Leila
  86. 86. Ahmad M. Abou Leila
  87. 87. Ahmad M. Abou Leila
  88. 88. In Aline leveling is not a problem but in CVP is CVP is very small number Ahmad M. Abou Leila
  89. 89. Ahmad M. Abou Leila
  90. 90. Accurate Zeroing Ahmad M. Abou Leila
  91. 91. Accurate Zeroing Ahmad M. Abou Leila
  92. 92. Ahmad M. Abou Leila
  93. 93. 1Injection of cold saline Measure the 3 Temperature change Entrance of cold saline 2 Ahmad M. Abou Leila
  94. 94. Ahmad M. Abou Leila
  95. 95. Ahmad M. Abou Leila
  96. 96. Ahmad M. Abou Leila
  97. 97. Ahmad M. Abou Leila
  98. 98. Ahmad M. Abou Leila
  99. 99. Ahmad M. Abou Leila
  100. 100. Ahmad M. Abou Leila
  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
  102. 102. Ahmad M. Abou Leila
  103. 103. Ahmad M. Abou Leila
  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
  108. 108. Ahmad M. Abou Leila
  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
  113. 113. Ahmad M. Abou Leila
  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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