Monitoring Journal Stresses Safety Equipment

N. Ty Smith, M.D.

J. Clin. Mon. Is Central Source of Data

Safety in anesthesia involves attention to detail and the ability to make proper decisions from the data available. The data comes from monitoring. To date, monitoring has been the major factor in the recent push towards total patient safety in anesthesia. The recent strong emphasis on monitoring has been so sudden that many of us have been caught unprepared for the rapid onslaught of changing technology, bewildering array of devices, and mandatory standards.

These drastic, relatively sudden changes in monitoring have forced us to buy expensive, sometimes complex devices that many anesthetists are not prepared to cope with; if they cannot cope with them, they may not use them, or they may use them improperly. Monitoring used improperly can be worse than no monitoring at all.

We need to know how to use our monitors, what they can do, what they cannot do, how to interpret the information that they provide, how to integrate the information from all of the monitors, how to troubleshoot a monitor, and when to buy a new one. Finding help in this area has not been easy, partly because the sources of information are so widely scattered: anesthesia, critical care, bioengineering, and engineering journals; obscure journals with limited distribution; poorly distributed proceedings; textbooks that are out-of-date before they are published, or literature from the manufacturer.

Inadequate Information

Unfortunately, even the information that has been available has not been sufficient. For example, there has not been enough information, other than anecdotal, to establish that any monitoring improves safety or saves lives. Information is also sparse on how to apply monitors and how to use the information that they give. The presence of a journal that encourages the exchange of information on these topics will help increase the availability of that information.

The Journal of Clinical Monitoring has approached these problems in many ways. First, it has improved communication between the innovators and manufacturers on the one hand and the users on the other, emphasizing clarity of presentation. We do not receive the technical training in medical school; they do not have the clinical insight that requires years to accumulate. Only by understanding each other can monitoring improve safety.

The Journal has strived to improve safety in many ways, most of them quite conventional: original articles, reviews, tutorials, medical intelligence, and case reports. The early years of monitoring emphasized the cardiovascular system. Lately, however, it has become apparent that over half of the major critical incidents are related to a lack of supply of oxygen to the tissues. Thus, the newer monitoring equipment has shifted towards respiration, a shift that is reflected in the journal. As a matter of fact, the Journal seems to be caught up in this trend: about one-third of its submissions are related to respiration, including pulse oximetry, capnography, and mass spectrometry. These are the very areas where a rapid dissemination of knowledge is essential for safety.

In exploring new ways to improve safety, the journal has been as practical as is consistent with W science. One of the most popular of the Journal’s innovative sections is the Clinical -Controversies, which has covered such topics as where should a central venous catheter be placed, when should it be placed, do we monitor too much, which is better the pulse oximeter or the transcutaneous oximeter, are evoked potentials useful in the OR, should we monitor alveolar and inspiratory concentrations of anesthetic and respiratory gases?

Future Controversies ask equally important questions: does monitoring make a difference in patient safety? Now that we have oximeters and capnometers, do we need continuous stethoscope monitoring Should we monitor patients receiving epidural opiates? Does mean arterial pressure have any physiological significance? Does one need a waveform with a capnometer? Is measuring drug concentrations needed in the OR? What one monitor would you take to a third world country?

Learn Equipment

Another feature that promises to be equally useful is one that will start in the next issue: “Knowing Your Monitoring Equipment”. In this section we shall ask the designers and manufacturers of commonly used monitoring equipment to explain how the equipment works and how it should be operated. Frequently such information is not available to the clinician because the manuals that come with the equipment often do not answer all the questions, sometimes they are written mom for the engineer than for the physician, and finally most equipment comes with only one manual, which is needed by many and often not available when needed.

The first essay will deal with the new method of continuous blood pressure employing the Penaz method, which is incorporated into a device marketed by Ohmeda under the trade name Finapres TM. In preparation is an essay dealing with infrared capno8raphy. In the planning stage are papers on pulse oximetry and electrocardiography. Readers who collect their issues of the Journal of Clinical Monitoring will accumulate over the years a valuable library on the operation of commonly used monitoring equipment.

Sometimes safety appears in the least expected places. For example, there is work on an EEG-based algorithm for detecting awareness during anesthesia. A reliable method for detecting awareness is important, because of the tendency to give an excess anesthetic to cover all patients, with possible unpleasant intraoperative or postoperative consequences for the occasional patient who is too sensitive to the anesthetic.

The Future

Monitoring will continue to change, and to change rapidly. Thus, the Journal will help the clinician prepare for the future by emphasizing now the future: automated record keeping, including voice recognition; servo control of drugs, machines, ventilators, etc.; monitoring of drug levels; continuous intravascular monitoring; and specific technologies, such as Raman spectroscopy.

This is your journal. Although the Editorial Board can assure high quality and readability, only you can let us know how well we have succeeded in our goals whether we have succeeded in helping you improve on patient safety in the operating room. What type of material or topics do you need to help you implement this important goal?

And please consider the journal as a medium for transmitting your ideas and thoughts to your colleagues. Manuscripts are always welcome. If you are interested in submitting a manuscript, please read over the Information for Contributors, to be found in the back of each issue. If you are interested in a subscription, either for yourself, or for your hospital, school, or departmental library, please contact Little, Brown and Co., 34 Beacon Street, Boston MA 02106, (617) 890-0250.

Dr. Smith, (an editor of the Journal of Clinical Monitoring), Department of Anesthesiology, V.A. Medical Center, San Diego, CA; is also an APSF Director.