CPM Summer 2018 - 4

daup h i n cm s .org

From the Editor

From Too Little to
Possibly Too Much

Joseph F. Answine, MD, FASA
Central PA Medicine Editor-in-Chief



Dauphin County Medical Society
777 East Park Drive, PO Box 8820
Harrisburg, PA 17105


Summer 2018 Central PA Medicine

Three or four decades ago, an anesthesiologist (which I am) had very little
information available to assure the safety of
a patient under anesthesia. Many patients
were anesthetized using only a manual blood
pressure cuff, stethoscope in the ear, a finger
on the carotid and visual assessment of the
color of the blood to determine whether
it was oxygenated or not. Very few if any
alarms werre available to determine whether
an appropriate amount of oxygen was being
delivered with the anesthetic gases via the
anesthesia machine. And, there were no
governors built into the machine to avoid
delivery of a hypoxic mixture. 
In 2018, our paients are monitored for,
at a minimum, a noninvasive blood pressure, a cardiac rhythm and rate, an arterial
oxygen saturation level, a temperature, an
end-tidal carbon dioxide (ETCO2) level and
ventilatory parameters such as tidal volume
and respiratory rate. Others monitors can
be added to measure bispectral analysis of
anesthetic depth, cerebral oximetry, continuous invasive hemodynamic measurements
(via a central line or arterial catheter),
noninvasive blood flow parameters such
as cardiac output and systemic vascular
resistance, and even intracranial pressure.
Our anesthesia machines have sensors for
inspired oxygen levels, peak and plateau
airway pressures; as well as fail-safes and
governors to avoid delivery of hypoxic gas
mixtures. And, there are alarms that sound
if any of the above are outside the normal
limits. We can perform laboratory studies
in the operating room including arterial

blood gas measurements, electrolytes, sophisticated coagulation studies and glucoses. 
So, are our patients safer now as compared
to decades ago? Without a doubt, yes they
are.  But, at what point does the constant
flow of high volumes of data just become
noise; too much information (sometimes
conflicting) to sift through as we care for
our patients? When do we have data overload?  When is it just a distraction? As for
distractions, we now deal with computer
charting with  the many mouse clicks and
boxes to fill in. 
Some voice concern about music in the
OR or the utilization of cellular phones and
electronic notebooks. Too much of that
type of stimulus can be distracting, but,
what about all the "required" distractions
such as the computer time logging in
data?  What about the onslaught of numbers
and waveforms that continuously dance in
front of our eyes?   
Above, I stated that the data can be conflicting. An example is a high intensity case
I was involved with where all the parameters
were normal except for the cerebral oximetry
readings which had dropped below the
20% threshold from baseline. The cerebral
oximeter is a relatively new device assessing
the adequacy of cerebral blood flow and
oxygenation. The case was going well and
all seemed stable from a surgical standpoint.
What to do? I applied the Fick Principle as
applied to oxygen delivery. Something first
discussed in 1870!  I assessed the variables:

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Table of Contents for the Digital Edition of CPM Summer 2018

CPM Summer 2018 - 1
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