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A method of recording electronic anaesthetic monitor data for research

Article  in  Anaesthesia · February 2017

DOI: 10.1111/anae.13794

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Correspondence
reduce medication errors in anaesthesia.
Anaesthesia 2016; 71: 1186–90.
2. Webster CS, Mason KP, Shafer SL. Threats
to safety during sedation outside of the
operating room and the death of Michael
Jackson. Current Opinion in Anesthesiol-
ogy 2016; 29: S36–S47.
3. Wachter R. The Digital Doctor - Hope,
Hype, and Harm at the Dawn of Medi-
cine’s Computer Age. New York:
McGraw Hill, 2015.
4. Merry AF, Webster CS, Hannam J, et al.
Multimodal system designed to reduce
errors in recording and administration of
drugs in anaesthesia: a prospective ran-
domised clinical evaluation. British Med-
ical Journal 2011; 343: d5543.
5. Houliston B, Parry D, Webster CS, Merry
AF. Interference with the operation of
medical devices resulting from the use
of radio frequency identification tech-
nology. New Zealand Medical Journal
2009; 122: 9–16.
doi:10.1111/anae.13796
Forcing functions and their
consequences – a reply
We thank Webster and Merry for
their interest in our prototype device.
We acknowledge that it is possible
many anaesthetists will not appreciate
being forced to follow a set of actions,
even if these actions were perceived
to increase patient safety. In the next
stage of device development, there-
fore, we are planning to introduce
and test a number of features that will
reduce workload and increase end-
user motivation for the system.
We agree that the likelihood of
system failure increases with its
complexity, but would like to
remind readers that the system
described in our paper is a proof-
of-concept prototype, and requires
further refinement.
Concerning Webster and
Merry’s final comment about our
power analysis, although the
© 2017 The Association of Anaesthetists of Great Britain and Ireland
primary outcome was achieved in
100% of the intervention group
compared with 36% of the control
group, the 95% confidence intervals
showed a potential compliance fail-
ure rate of ~4% for the sample size
we selected, which we acknowl-
edged as a limitation in our paper.
S. A. Khan
S. Khan
H. Kothandan
Singapore General Hospital,
Singapore
Email:
shariq.ali.khan@singhealth.com.sg
No external founding or competing
interests declared. Previously posted
on the Anaesthesia correspondence
website: www.anaesthesiacorrespon
dence.com
Reference
1. Khan SA, Khan S, Kothandan H. Simu-
lator evaluation of a prototype device
to reduce medication errors in ana-
esthesia. Anaesthesia 2016; 71:
1186–90.
doi:10.1111/anae.13807
A method of recording
electronic anaesthetic
monitor data for research
Several recent ‘big data’ observa-
tional studies have found a correla-
tion between intra-operative
hypotension and poor outcome
[1–3].
However, although the 5th Edi-
tion of the AAGBI: Recommenda-
tions for standards of monitoring
during anaesthesia and recovery [4]
recommended the use of automated
electronic anaesthetic record
Anaesthesia 2017, 72, 262–273
systems, they do not mandate them
(yet), on the grounds of cost [5].
We have previously argued that the
AAGBI should insist on automated
electronic data capture in the next
iteration of the guidelines to stimu-
late manufacturers’ interest, and
encourage hospitals’ investment in
such systems for medicolegal and
research purposes [6].
At the AAGBI Annual Confer-
ence in Birmingham, September
2016, SW asked Draeger and GE
Healthcare whether they made
small, inexpensive hardware devices
that recorded anaesthesia monitor
data and converted it for spread-
sheet/research analysis. Neither
produced devices commercially
(although they were used for equip-
ment diagnostics and theatre net-
work connectivity [7]), so we
identified our own strategy for
recording and storing data, which
we would like to share with
research colleagues.
The following, easily available
hardware is required: a laptop com-
puter, connected to a Keyspan
(Tripp Lite, Newbury, UK) RS-232/
DB9 (male) USB high-speed
(230 kbps) PC/Mac serial adapter,
connected to a StarTech (North-
ampton, UK) DB9 RS232 serial null
modem adapter (female/female),
connected to an ATEN (ATEN
Technology, Irvine, CA, USA)
UC232A USB to serial converter
(male/USB), connected to USB port
4 of the anaesthetic monitor
(Fig. 3), the total cost of which is
~£50 (US$62, €58). The Keyspan
adapter needs to be configured via
https://www.tripplite.com/support/
USA19HS; any recognised serial to
USB adapter should work provided
267
Anaesthesia 2017, 72, 262–273
Figure 3 Hardware setup, enabling monitor data transfer to laptop
computer.
the appropriate drivers are installed
on the host computer. The total
one-off cost of these adapters is
around ~£50 (US$62, €58).
Two free software programs per-
mit data capture onto Apple (Cuper-
tino, CA, USA) MacBook Air or Pro
devices – Monitor2 (James Derrick,
2014, iTunes, free) and Vital Signs
Capture (VSCapture, www.source-
forge.net). The former provides a
polished graphical interface and per-
mits the recording of drugs, inter-
ventions and production of a
customisable chart as well as allow-
ing the record to be saved in an
encrypted format. The latter pro-
gram provides a more basic com-
mand line interface and needs to be
compiled either using the ‘Mono’
framework (www.mono-project.
com) or Xamarin Studio (www.xam
arin.com). It allows direct capture of
the data to a comma separated value
(.csv) file at a frequency chosen by
the user. Both programs allow the
captured data to be easily imported
into an Excel (Microsoft, Redmond,
WA, USA) spreadsheet for onward
268
analysis, saved as a password-pro-
tected, encrypted file.
Monitor2 requires the user to
conform the serial port connected
to the laptop. The default settings
of 19200 baud, 8 data bits, 1 stop
bit and Even parity are correct for
GE Healthcare (Little Chalfont, UK)
AS3 based anaesthetic monitors.
Recording frequency can be set in
the preferences as low as 0.5 s
(maximum 120 s, default 5 s).
VSCapture uses the same hard-
ware setup and prompts the user to
select the port in use. It then allows
the user to select the logging interval
(≥ 5s) before generating a log file.
From a research perspective,
automated recording of haemody-
namic data reduces measurement bias
[8], provides much greater informa-
tion than intermittently recorded data
or pre-induction vs. intra-operative
nadir values [1–3], and should enable
further insight into which aspects of
hypotension (absolute/relative values,
rate of change, duration, or combina-
tions of these) are most correlated
with ‘ischaemic’ end-organ outcomes
© 2017 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
(delirium, acute coronary syndrome,
acute kidney injury) in research stud-
ies.
S. M. White
J. Pateman
Brighton and Sussex University
Hospitals NHS Trust,
Haywards Heath,
Brighton, UK
Email: stuart.white@bsuh.nhs.uk
SW is an Editor of Anaesthesia, and
this letter has been reviewed exter-
nally. Neither SW nor JP has any
financial interest in either the soft-
ware or hardware mentioned in this
letter. No external funding or com-
peting interests declared.
References
1. Walsh M, Devereaux PJ, Garg AX, et al.
Relationship between intraoperative
mean arterial pressure and clinical out-
comes after noncardiac surgery: toward
an empirical definition of hypotension.
Anesthesiology 2013; 119: 507–15.
2. Sessler DI, Sigl JC, Kelley SD, et al.
Hospital stay and mortality are
increased in patients having a ‘‘triple
low’’ of low blood pressure, low bispec-
tral index, and low minimum alveolar
concentration of volatile anesthesia.
Anesthesiology 2012; 116: 1195–203.
3. White SM, Moppett IK, Griffiths R, et al.
Secondary analysis of outcomes after
11,085 hip fracture operations from the
prospective UK Anaesthesia Sprint Audit
of Practice (ASAP 2). Anaesthesia 2016;
71: 506–14.
4. Checketts MR, Alladi R, Ferguson K,
et al. AAGBI: recommendations for stan-
dards of monitoring during anaesthesia
and recovery 2015. Anaesthesia 2016;
71: 85–93.
5. White SM. Automated electronic anaes-
thesia records. Anaesthesia 2016; 71:
850–1.
6. Checketts MR. Electronic anaesthesia
records – a reply. Anaesthesia 2016; 71:
850–1.
7. GE Healthcare. Capsule supported con-
nectivity for the perioperative care area.
http://www3.gehealthcare.com/~/me
dia/documents/us-global/products/
 Correspondence
patient-monitoring/productspecsheet/
networking/ge%20capsule%20connect
ivity%20sell%20sheet_v9%20-%20doc
1404371.pdf (accessed 23/11/2016).
8. Mengden T, Asmar R, Kandra A, Di Gio-
vanni R, Brudi P, Parati G. Use of auto-
mated blood pressure measurements in
clinical trials and registration studies:
data from the VALTOP Study. Blood Pres-
sure Monitoring 2010; 15: 188–94.
doi:10.1111/anae.13794
Inadvertent carotid
catheterisation
Murphy’s law states that ‘anything
that can go wrong, will go wrong’.
The consequences of things ‘going
wrong’ in anaesthesia can be disas-
trous, as illustrated in the letter by
Plummer and Lavinio [1]. Despite
the widespread reporting of devas-
tating complications, incidents, for
example, such as flushing an arterial
line with dextrose or the injection of
thiopentone into an artery, continue
to occur in our hospitals. Alas, we
anticipate that this will likely not be
the last time that a carotid artery is
inadvertently catheterised.
As such, we wish to comment
on certain safety-related aspects of
Plummer and Lavinio’s letter, in
light of the AAGBI: Safe vascular
access guidelines 2016 [2]. There is
no mention of whether ultrasound
was used to site the line. It is com-
monly accepted that ultrasound
reduces the risk of arterial puncture,
yet it does not eliminate it. From
our own clinical practice, we have
observed the use of dangerous
puncture techniques amongst ultra-
sound-trained clinicians for central
venous line insertion, such as steep
or medial angulation of the needle
or transfixing the vein against the
© 2017 The Association of Anaesthetists of Great Britain and Ireland
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artery. Change in practice amongst
exclusively ultrasound-trained clini-
cians is corroborated by a recent
observational study by Shelton et al.
[3].
We believe that more needs to
be done to emphasise the following
safety points to the wider anaes-
thetic community. Ultrasound use
should be combined with an
anatomical approach to puncturing
the vein, by needling at a shallow,
lateral angle whilst aiming for the
ipsilateral nipple. Operators should
be aware that they will not be able
to see the needle tip with an out-
of-plane technique and should
therefore always note the colour
and pulsatility of blood from the
needle. The neck should be thor-
oughly scanned to note the place-
ment of the wire in the correct
vessel. Finally, checks should
always be performed before using
any central venous line, such as a
combination of pressure transduc-
ing (prior to dilation, if there are
concerns) and venous gas sampling,
to check the PaO2. Despite this,
arterial puncture always remains a
possibility and there is no perfect
technique or test to prevent its
absolute occurrence.
M. Charlesworth
A. D. Ashworth
University Hospital South
Manchester,
Manchester, UK
Email: mda05mc@gmail.com
No external funding or competing
interests declared. Previously posted
on the Anaesthesia correspondence
website: www.anaesthesiacorrespon
dence.com
Anaesthesia 2017, 72, 262–273
References
1. Plummer MP, Lavinio A. Stroke following
inadvertent carotid artery catheterisa-
tion. Anaesthesia 2016; 71: 1370.
2. Shelton CL, Mort MM, Smith AF. Tech-
niques, advantages, and pitfalls of
ultrasound-guided internal jugular can-
nulation: a qualitative study. Journal of
the Association for Vascular Access
2016; 21: 149–56.
3. Bodenham A, Babu S, Bennett J, et al.
AAGBI: Safe vascular access 2016.
Anaesthesia 2016; 71: 573–85.
doi:10.1111/anae.13791
Epidural pump malfunction
We would like to report the mal-
function of an epidural pump
(CADDâ-Solis Model #2110 CE;
Smiths Medical ASD Inc., Oakdale,
MN, USA) that led us to question
epidural placement in two obstetric
patients, in the absence of any
error message being displayed on
the pump.
Following initial epidural pain
relief during labour, breakthrough
pain after one hour required top-up
administration of 10 ml ropivacaine
0.2%, despite apparent continuous
epidural infusion. After a further
hour, this process repeated itself after
a lack of sensory level to cold was
noted. The patient opted to have
epidural replacement, obtained rea-
sonable pain relief, and delivered
within another hour. A second patient
admitted to the same labour room
experienced similar problems with a
non-functioning epidural. On this
occasion, we discovered that the
epidural infusion bag was not empty-
ing, and the pump, while appearing to
be functional, was not delivering the
set dosage. We promptly removed the
pump and replaced it with another
269