When Numbers Are Wrong!

(Pitfalls In Anesthethesia Monitoring)

Dr.Anupam Goswami Professor & Head Department of Cardiac Anesthesiology I.P.G.M.E&R KOLKATA
Dr.Sandeep Kumar Kar Rmo-cum clinical tutor Department of Cardiac Anesthesiology I.P.G.M.E&R KOLKATA

INTRODUCTION
Heisenbergs uncertainty principle The very act of measuring a physiologic variable may affect the value of that variable. It is therefore appropriate to the use in practice of imperfect measures of the status of our patients with humility . Be vigilant for potentially misleading information.

Uncertainty principle and our measurement systems

A more formal inequality relating the standard deviation of position x and the standard deviation of momentum p was derived by Heisenberg in 1927 x*p >= h/4 where x is the uncertainty as to the particle's position and p is the uncertainty as to its momentum (and thus its velocity).

What We Infer?
Historically, the uncertainty principle has been confused with a somewhat similar effect in physics, called the observer effect, which notes that measurements of certain systems cannot be made without affecting the systems. Uncertainty principle is inherent in the properties of all wave-like systems How can our Haemodynamic waveform whether IBP, CVP , ECG escape from it?

The ideal Clinician:

The practitioner must be : 1)Aware of potential sources of error in measurement and interpretation. 2)Interpret data in context 3)Consider the entire picture of the patient. 4)Should not view the data as a collection of independent variables.

Invasive Blood Pressure Monitoring

It is not uncommon for discrepancies to occur between invasive and noninvasive measurements of blood pressure resulting in confusion at the bedside over which number to use in directing therapy.

Invasive Blood Pressure Monitoring

Physical properties of the system being measured have significant influence on the potential errors. The vascular system is complex, with periodic variations in pressure following each heart beat over a wide range of frequency. The high heart rate of infants interfered in responsiveness and ideality of the transduced waveforms early in development of monitoring devices

The Real Problem In Accurate Monitoring

Transmission of the pressure waveform down a progressively smaller, branching vascular tree with variable elastance and resistance depending on humoral and neural regulation of vascular tone. In clinical situations associated with increased resistance (hypovolemia, early compensated shock), reflection of kinetic energy back from the vascular tree to the end-hole vascular cannula can giveSBP

Damping
Damping of the pulse waveform is associated with falsely low systolic pressures and falsely high diastolic pressures. Most common cause : 1.vasospasm of the vessel in which the cannula lies. 2. Air bubble in the fluid-filled tubing leading from the vascular cannula to the electronic transducer. 3. Loose connection in the tubing

How to Reduce Damping?

Make tubing bubble-free. Ensure there are no loose connections. Adding papaverine to the arterial line infusate is often helpful in reducing vasospasm at the site of the line insertion, which may result in a better waveform and more reliable pressure measurement. Use MABP in guiding therapy

Why MABP?

It is a function of the area under the arterial pulse waveform curve and is less affected by damping of the signal.

The Problem of Resonance

Resonance refers to the interaction between the natural frequency of a physical monitoring system and the frequency of the physiologic parameter being measured. This causes erroneous waveforms and pressures to be displayed.

The natural frequency of a tubing/transducer system is not dissimilar to that of a xylophone, so that the monitoring system itself may, with its intrinsic physical properties, influence the data generated. Using stiff, noncompliant, narrow gauge, and short tubing. It is common to seeflingelevation of the SBP visible as a needle point at the peak of the pulse waveform as the system are set up to reduce damping of the signal

How To Reduce Resonance?

Catheter whip due to movement

Catheter whip due to movement within the vessel in a hyperdynamic circulatory state may impart kinetic energy to the end hole of the cannula, resulting in a higher pressure measurement. This is more in catheters placed in larger central arteries or the aorta or pulmonary artery.

Strive for Excellence!

Noninvasive Blood Pressure Monitoring Two methods: 1) Auscultation of Korotkoff sounds. 2) Oscillometric Method( Automated) Both the methods depend on flow being present in the extremity being subjected to assessment. Unreliable in low flow states The effect of kinetic energy component in IBP monitoring makes intraarterial IBP 8-16 Torr higher than NIBP normally and 25-30 Torr higher in Sepsis.

Pitfalls in noninvasive blood pressure monitoring

Data acquisition is intermittent rather than continuous making it more difficult to assess response to therapy with titration. Severe vasoconstriction may make noninvasive blood pressure measurements unobtainable. Cuff size must be appropriate to acquire accurate measurements.

DETERMINANTS OF CARDIAC OUTPUT

Cardiac output is the product of stroke volume and heart rate. Determinants of stroke volume include

Preload, Contractility Afterload.

Easy question?

What

is the most direct physiological measure of Preload?

The Answer comes

Measurement of fiber length in the sarcomere at end-diastole This is not clinically feasible

What is the solution?

Extrapolation from measurements that are clinically available is necessary. But. With each step away from direct measurement there is more potential error in measurement and interpretation.

Contractility
Contractility is also an extrapolated assessment in clinical practice Either derived from hemodynamic calculations or echocardiographic visual evidence involving measurements themselves subject to error.

Afterload?
Clinically recognized by physical examination. Qualitatively assessed if anatomic abnormalities or abnormal flow patterns are present by echocardiography. Quantitatively calculated if pulmonary artery catheterization is performed. All methods are subject to errors in interpretation. Why?

We need to be Realistic

Despite the difficulties in measurement and interpretation, such data can be successfully incorporated into goal-directed therapeutic algorithms with a holistic clinical approach leavened by knowledge of the pitfalls.

And Remember this person

x*p >= h/4

Preload Assessment(CVP)
Being utilized to assess a remote leftsided volume As a right-sided pressure measurement being utilized to assess a remote left sided volume parameter, left ventricular end diastolic volume(LVEDV), numerous factors may result in a misleading value. In pediatric patients isolated LV dysfunction is not reflected in high CVP measurements but must be kept in mind.

Myocardial infarction related to anomalous left coronary artery arising from the pulmonary (ALCAPA) Kawasaki disease with coronary aneurysms. Acute myocarditis or cardiomyopathy related to various metabolic disorders may also present with significant left ventricular (LV) dysfunction not necessarily reflected by a high CVP if right ventricular (RV) compliance is normal.

Preload Assessment(CVP)

A stiff ventricle, either on the right or the left side, may result in a high pressure even if the left ventricle is under filled pericardial effusion with tamponade, constrictive pericarditis, or high pericardial pressure secondary to high ventilatory pressures may produce high filling pressures with low end-diastolic volume Obstructions to left ventricular emptying such as aortic valvular stenosis produce a high end-diastolic pressure.

Ventricular Compliance

Any anatomic or pathophysiologic cause of increased resistance to left ventricular filling situated between the tip of the catheter and the left ventricular chamber may result in misleading high pressure readings suggesting adequate preload is present. On left side:MV disease, Pulmonary Venous ObstructionOn The right side:Pulmonary Hypertension, PVD,PE, TVD, R-L shunts,all these obfuscate the true volume status of LV by producing high pressure measurement

Ventricular Compliance

How Much We Rely on CVP

Observation of the response to volume expansion with continuous monitoring of the CVP can help identify adequate volume loading and prompt addition of inotropic support. Echocardiography comes to our rescue in case we get dubious results. The knowledge of abnormal wave forms in CVP

Pulmonary artery occlusion pressure (PAOP)

The assumption may be made that pulmonary artery occlusion pressure accurately reflects intravascular volume status and left ventricular preload. PAOP may be high in LV dysfunction and Mitral valve disease with decreased compliance, prompting the potentially incorrect conclusion that luid resuscitation hasbeen adequate or excessive.

Airway Pressure & PAOP

Airway pressure is another very important factor in interpretation of the PAOP in patients receiving positive pressure ventilatory support. placement of the catheter in West Zone III to achieve a continuous fluid column between the catheter tip and the LV Placement in upper lobes or anterior segments with relatively more inflation of alveoli than pulmonary blood flow, West Zone I, will exaggerate the effect of PPV on the measurement causing misleading high value.

The Cause of erroneous PAOP

If the respiratory cycle alveolar airway pressure exceeds pulmonary venous pressure, thereby interrupting pulmonary blood low through vascular compression High levels of positive ventilatory pressure may convert the monitored lung site from optimal West Zone III to Zone II (lower low to ventilation ratio) despite proper initial placement of the catheter tip in a dependent lower lobe.

Avoiding this Pitfall

Careful measurement of PAOP at endexpiration as judged by observation of respiratory variation in the pressure tracing Aggressive diuresis resulting in hypovolemia may cause the conversion of Zone III lung physiology to that of Zone II, causing misleadingly high PAOP in volume-depleted patients on high levels of PEEP.

Contractility Assessment
Contractility is defined as the velocity of myocardial fiber shortening. Measuring approximating stroke volume as a marker of contractility are subject to the influence of afterload and valvular regurgitation. High afterload secondary to valvular stenosis or increased systemic vascular resistance will decrease stroke volume even with normal contractility.

Contractility Assessment
Pharmacologic vasodilation can increase stroke volume even with poor contractility. Valvular regurgitation may effectively reduce afterload allowing a large stroke volume, partially in the wrong direction with a net result of inadequate systemic low. Estimations of contractility via nuclear medicine scans or calculations based on data derived from thermodilution pulmonary artery catheters are subject to the same confounding factors

Afterload Assessment Pitfalls

Pitfall in interpretation of a high PAP is that high flow due to L-R shunt may produce a high pressure even in the presence of normal pulmonary vascular resistance. Echocardiographic data estimating resistance via flow patterns is available only intermittently and is subject to error.

Cardiac Output Assessment

Operator variation, computational errors, Based on the assumption that there is no intracardiac shunt through septal defects. Other confounding conditions which may invalidate the measurement include tricuspid regurgitation, atrial arrhythmias, and variation in timing of the respiratory cycle with indicator injection.

Echocardiography
Low estimation depends on the cross-sectional area of the vessel being evaluated; a high flow across a narrow vessel may not represent adequate output. Measurements of ejection fraction and shortening fraction may suggest a higher systemic output than exists due to mitral valve regurgitation or aortic insufficiency.

Capnography
Pitfalls in interpretation are revealed when arterial blood gases are performed showing a gap between paCO2 and ETCO2 ,and include: 1) severe airway or parenchymal lung disease causing significant ventilationperfusion mismatch, resulting in dead-space ventilation and a false low ETCO2 2) false low value because of failure to obtain a true alveolar sample due to expiratory obstruction.

Pulse- oximetry limitations

Carbon Monoxide Carbon monoxide molecules, even in a small amount, can attach to the patient's hemoglobin replacing oxygen molecules. A pulse oximeter cannot distinguish the differences and the reading will show the total saturation level of oxygen and carbon monoxide. If 15% of hemoglobin has carbon monoxide and 80% has oxygen, the reading would be 95%.

Pulse- oximetry limitations

Blood Volume Deficiency Conditions, such as hypovolemia, hypotension, and hypothermia, may have adequate oxygen saturation, but low oxygen carrying capacity. Due to the reduction in blood flow, the sensor may not be able to pick up adequately the pulsatile waveform resulting in no signal or loss of accuracy.

Pulse- oximetry limitations

Skin Pigmentation Dark skin pigmentation can give overestimated SpO2 readings when it is below 80%. Find a place where the skin color is lighter. Intravenous Dyes Intravenous dyes (such as methylene blue, indigo carmine, and indocyanine green) can cause inaccurate readings.

Pulse- oximetry limitations

External Interference Exposure to strong external light while taking measurement may result in inaccurate readings.

Shield the sensors from bright lights.

Methemoglobin is a form of hemoglobin that does not carry oxygen. It is normal to have 1-2% of haemoglobin in this form. A high level of methaemoglobin would cause a pulse oximter to have a reading of around 85% regardless of the actual oxygen saturation level.

Pulse -oximetry and Methemoglobenemia

A serious Pitfall. Misleading Numbers!

Alveolar hypoventilation is the main form of respiratory failure postoperatively results from combinations of central respiratory depression,muscular weakness, and upper airways obstruction. As arterial carbondioxide tension rises so does alveolar carbon dioxide tension (Pco2); alveolar Po2 falls, leading to arterial hypoxaemia. This is diagnosed very late if the patient in on supplemental 02 or Anesthesia

Electrocardiography Artifacts

Electrocardiography Artifacts

Electrocardiography Artifacts

Electrocardiography Artifacts

Electrocardiography Artifacts

Electrocardiography Artifacts

REFERENCES
1. Swedlow DB, Cohen DE. Invasive assessment of the failing circulation. Clinics in Critical Care 2. Clark JA, Lieh-Lai MW, Sarnaik A, Mattoo TK. Discrepancies between direct and indirect blood pressure measurements usingvarious recommendations for arm cuff selection. Pediatrics. 2002;110(5):920-923. 3. Pinsky MR. Clinical signfiicance ofpulmonary artery occlusion pressure. Intensive Care Med. 2003;29:175-178.

4.SM, Murdoch IA. Monitoring cardiac function in intensive care. Arch Dis Child. 2003;88:4652. 5.Piehl, MD, Manning J, McCurdy SL, et al. Comparison of pulse contour analysis with pulmonary artery thermodilution in 2004 Pediatric Critical Care. 6. Egan JR, Festa M, Cole AD, et al. Clinical assessment of cardiac performance in infants and children following cardiac surgery. Intensive Care Med. 2005;31:568-573.

REFERENCES

Are we living in the world of Approximations?

THINK

THANK YOU