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PubMed2006

Critical care in the emergency department: monitoring the critically ill patient.

The aim of monitoring patients is to detect organ dysfunction and guide the restoration and maintenance of tissue oxygen delivery. Monitoring is a crucial part of the care of the critically ill patient in the emergency department as the physiological response to critical illness is linked strongly to outcome. As it is important to appreciate the limitations of monitoring systems and monitored data, and to understand that invasive monitoring may be hazardous, this review concentrates on the techniques used to monitor critically ill patients in the emergency department. End tidal carbon dioxide monitoring, pulse oximetry, arterial blood pressure monitoring, central venous pressure monitoring, continuous central venous oxygenation saturation monitoring, temperature monitoring, and urine output are discussed. Practitioners should be familiar with the physiology and technology underlying these monitoring techniques and be aware of the pitfalls in interpretation of monitored data.

Aged↗
PubMed2004

An economic model of 2-hour post-dose ciclosporin monitoring in renal transplantation.

BACKGROUND: Monitoring of microemulsion ciclosporin (cyclosporine; Neoral) by 2-hour post-dose drug concentrations (C2) is an accurate measure of ciclosporin absorption efficiency and exposure, and appears superior to trough (C0) monitoring for prediction of rejection risk. A predictive decision model was used to determine if this approach also reduces total treatment costs in the first 12 months after renal transplantation. METHODS: Parameter estimates for key clinical events were derived from the literature and from prospective pharmacokinetic studies comprising 234 adult HLA-non-identical renal graft recipients at seven Canadian centres. Patients were treated with microemulsion ciclosporin (Neoral), corticosteroids and azathioprine or mycophenolate mofetil. Using the perspective of the Canadian healthcare provider, total treatment costs for the C2 versus the C0 strategy were modelled over 12 months, and then remodelled using conservative estimates to extend the timeframe to 5 years. Health resources were valued in 1999 Canadian dollars. RESULTS: The incidence of acute rejection was estimated to be 25% at 1 year in patients monitored by C0 and 18% in those monitored by C2. Patient survival was considered to be independent of monitoring strategy, and graft loss was predicted to be 1.4% lower in the C2 group. The studies suggested no important differences in comorbidity and the costs of C0 and C2 monitoring and ambulatory-based adverse events were held equivalent. Using these inputs, the average cost per patient for the first year post-transplant was Can dollars 46,857 for C0 monitoring and Can dollars 45,306 for C2 monitoring, rising to Can dollars 146,879 and Can dollars 142,569 after 5 years. The predicted cost for initial hospitalisation was Can dollars 11,280 for C0 and Can dollars 10,806 for C2 monitoring. The cost of maintenance immunosuppressive drug use, graft loss and dialysis was Can dollars 19,098 in the C0 group and Can dollars 18,612 in the C2 group, while acute rejection treatment costs were Can dollars 2169 and Can dollars 1577, respectively. An additional Can dollars 14,310 was consumed by other events, including repeat hospitalisation, for each group. Sensitivity analysis indicated that the most influential parameters affecting savings due to C2 monitoring were a reduction in the duration of initial and follow-up hospitalisations and reduced risks of acute rejection and subsequent graft loss. CONCLUSIONS: Compared with traditional trough concentration monitoring, ciclosporin monitoring at 2 hours post-dose produced a predicted saving of Can dollars 1551 during the first year after renal transplant. Although modelling assumptions become more restrictive over time, this projection allows a preliminary assessment of the long-term economic impact of the routine use of C2 monitoring.

Adult↗
PubMed2000

[Study of how to continue peak flow monitoring for patients with bronchial asthma: questionnaire to continuation and interruption patients].

Since 1993, our hospital has actively pursuing introduction of peak flow monitoring for patients with bronchial asthma. However, a number of patients are found to discontinue PEF monitoring. In order to determine the causes, a comparative analysis of recognition between patients who continued PEF monitoring (continuation group, hereafter) and those who discontinued PEF monitoring (interruption group, hereafter) was conducted through a questionnaire survey. The number of patients with bronchial asthma who responded to the questionnaire was 120; among them, the number of cases who continued and interrupted PEF monitoring were 68 and 52, respectively. The percentage of patients whose symptoms improved after the introduction of PEF monitoring was higher in the continuation group than in the interruption group. Approximately half of the patients in the interruption group commented that PEF monitoring was valid. The percentage of patients who believed that PEF monitoring is valid was higher in the group of patients who experienced reduction in the severity of symptom after introduction of PEF monitoring compared with those who did not. From these results, to keep high compliance of PEF monitoring, we propose that introduction of PEF monitoring and education of self-management should be positively stated for patients in unstable state. Furthermore, we found that some of the patients in the interruption group expressed interest in restarting PEF monitoring, indicating that each patient should be dealt with on a case by case basis. Appeals from doctors, patients education and advice of relatively few measurements, were found to be especially important in motivating patients to use PEF monitoring.

Asthma↗
PubMed1995

Aggressive use of ICP monitoring is safe and alters patient care.

OBJECTIVE: To identify complications and interventions resulting from fiberoptic ICP monitoring in a large series of patients with closed head injury (CHI). SETTING/DESIGN: Level I trauma center/Consecutive case series. METHODS: Of 11,962 consecutive trauma admissions from 1984-1991, 279 patients underwent fiberoptic ICP monitoring for CHI. We identified the last 100 consecutive blunt trauma patients who had received ICP monitoring. Ninety-eight of these patients had charts available and constitute the study group. We examined mortality, Glasgow Coma Score (GCS), and admission CT findings for the group. Indications, interventions, and complications (bleeding, meningitis, and wound infections) associated with ICP monitoring were identified. RESULTS: Mortality for the group was 24%. Reasons for ICP monitoring included GCS < or = 8 and/or abnormal CT findings; 83% had GCS < or = 8. Admission CT findings included subarachnoid hemorrhage (48%), intracerebral hemorrhage (47%), edema (31%), intraventricular hemorrhage (20%), subdural hematoma (18%), and epidural hematoma (9%). Eighty-one per cent of patients had interventions based on ICP monitoring: osmolar therapy (81%), emergency CT (22%), surgical decompression (3%), or pentobarbital coma (2%). No complications resulted from ICP monitoring. Mean duration of monitoring was 4 days (maximum 13 days). Twenty patients (20%) required two or more monitors. Reasons for placing a second monitor included duration > 5 days (50%), questionable accuracy (20%), and accidental removal of the first monitor (10%). CONCLUSIONS: 1) Fiberoptic intracranial pressure monitoring leads to specific interventions in the majority of patients. 2) The procedure is safe. 3) Prospective studies are needed to determine the impact of coagulopathy on the safety of fiberoptic intracranial pressure monitoring and to define those factors responsible for the low infection rate.

Adolescent↗
PubMed1993

[Computer-aided anesthesia monitoring. Experiences with the use of three systems in heart surgery].

Basic monitoring in cardiac anaesthesia embraces at least 19 different parameters of haemodynamics and blood gas analysis. In special cases additional measurements may be desirable, providing a total of up to 44 variables displayed on various monitors, as depicted in Fig. 2. The recording of such an amount of data is only feasible with automated recording systems. Therefore, in the past 6 years we have introduced three different computer systems to our cardiac anaesthesia workplaces. The experiences in their handling are reported. MATERIAL AND METHOD. Three systems were investigated: (1) System S 4000 (Siemens, Germany), based on a central processor unit (PDP 11, DEC, Japan) connected with 20 bedside input/output terminals and Sirecust 404a monitors (Siemens). The system collected the data in a ring buffer with a capacity for about 24-48 h. (2) Patient Care Manager (PCM; Siemens, Germany), a single workplace system based on an IBM-compatible personal computer (PC) with the operating system environment DOS 5.0/Windows 3.0. In our test configuration it was connected with a Sirecust 1281 monitor (Siemens). (3) Monitor-Data-Manager (MDM) (our own development). This single workplace system is also based on an IBM-compatible PC running under DOS and was connected to four different monitors used in our cardiac surgery operating theatre (Fig. 2). A second computer (Sirecust S 425, Siemens) served as an interface between the two 404 monitors (not featuring a serial output like RS 232) and the PC. The self-developed program for that interface was memory resistant and executable with three key presses when the anaesthetic record was started. The three systems were compared with regard to their ease of use, function and practicability. RESULTS. System S 4000: Because of the older system architecture, the response time to key inputs was fairly long and the menu structure somewhat uncomfortable. A major drawback was the limited data buffer capacity and the lack of a long-term storage medium as well as the lack of compatibility with the industry standard for PCs. Software interfaces to other companies' monitors were not implemented, limiting the system to the Sirecust 404 devices. Patient-Care-Manager: The user interface is a Windows 3.0 application representing an up-to-date graphical environment. Unfortunately some Windows features were not fully used, e.g. the free positioning and sizing of graphic windows and the color options. Drug inputs were somewhat long-winded, limiting the system's suitability for the operating theatre. The main disadvantage, however, was the lack of interfaces to monitors other than those from Siemens. Monitor Data Manager: The system was designed to sample data from all monitors operating in our hospital's heart surgery department. Each parameter was displayed in a digital form to get close control over the recorded data (Fig. 1b); additionally calculated values like total peripheral resistance or oxygen demand could be drawn from a separate window. Furthermore, key inputs were reduced to minimum, making drug inputs faster than the hand-written protocol. The ease of performing calculations of continuous drug infusions (from microgram/kg/min to ml/h pump speed) was particularly appreciated by the users. Since the data were saved as an ASCII file, they could easily be imported by any spreadsheet like Lotus 1-2-3 or Excel, providing the whole variety of their graphical presentation or calculation features. Because of the high sampling rate (3 min), even short-lasting drug effects could be registered, making the system favourable for scientific studies. CONCLUSION. Automated monitor data record systems are considered to be a prerequisite not only for research in anaesthesia but also for quality assurance. A basic requirement for wide acceptance in clinical practice is a user interface that provides fast and convenient key inputs as well as further information about parameters not displayed on other monitors. In our h

Anesthesia↗
PubMed1998

Comparative accuracy of glucose monitors.

BACKGROUND: Self-monitoring of blood glucose levels has become an important instrument for the management of patients with diabetes mellitus. Both patients and physicians expect that the monitors will provide reliable results. Numerous environmental, physiologic, and operational factors can affect system performance, yielding results that are inaccurate or unpredictable. METHODS: This study examined the effect of one factor--high altitude--on the performance of seven blood glucose monitoring systems. The following monitors were compared: two One Touch II; two One Touch Basic; two Reflolux II (Accu-Chec in the USA); two Glucometer 3; one Glucometer 2, and one Accutrend Alpha. Double blood glucose level values were compared with a controlled reference laboratory test value, which was unknown to the investigator until the end of the study because the study was double blind. Blood glucose values were obtained using each of the monitors in 200 patients; 150 with diabetes mellitus, and 50 healthy subjects. RESULTS: The One Touch monitors were the only monitors that reported adjusted straight lines (Y = a+bX) that were very similar for all three techniques. In addition, these adjusted straight lines are those closest to the ideal line, Y = X. These same monitors were the only ones that did not reject the null hypothesis Ho: a = 0. The relative deviation index at the 20% level was less than 3.5% for the One Touch II and One Touch Basic monitors; for the rest of the monitors, the index was over 14%. The clinically accepted EGA region was similar for all study monitors. CONCLUSIONS: In conclusion, the One Touch II and One Touch Basic Monitors showed greater accuracy in comparison to the other devices. The evaluation of the clinically acceptable region shows practical reliability for all of the monitors used.

Adolescent↗
PubMed1999

Potential utility of electronic drug compliance monitoring in measures of adverse outcomes associated with immunosuppressive agents.

Poor compliance with prescribed medications limits the effectiveness of many pharmacologic therapies and enhances their potential toxicities. Traditional methods of measuring drug-taking behavior, including direct observation, patient self-report, pill counts, and therapeutic drug level monitoring, all have well-described limitations in validity and interpretability. Electronic medication event monitoring has been used to assess compliance with therapies for hypertension, glaucoma, anemia, and epilepsy, overcoming many problems of traditional approaches. However, no published reports describe the use of electronic monitoring with immunosuppressive agents, despite their increasing use for non-life-threatening conditions and their many dose-dependent toxicities. Transplant recipients are thought to be at particular risk from noncompliance. Therefore, we undertook this study to assess the feasibility of electronically monitoring compliance with immunosuppressive drugs among renal allograft recipients. Twenty-five kidney transplant patients receiving immunosuppressive medications from a single pharmacy were enrolled. Each subject received electronic monitors with their immunosuppressive serum drug refills for cyclosporine and azathioprine. Each subject returned their monitors after the first month of this 2-month study for downloading data. The frequency distribution of interdose intervals were described. Two measures of average non-compliance were calculated for both drugs: the proportion of monitored days that had missed doses, and the proportion of missed doses. Once daily and twice daily regimens of cyclosporine were compared. Concordance in drug compliance between the two drugs was calculated for each subject and averaged over the study population. Twenty-two of 25 subjects missed one or more doses of cyclosporine or azathioprine. Seventeen (68%) subjects never missed four or more consecutive doses. Subjects were non-compliant with cyclosporine on 8.7% of monitored days, and non-compliance with azathioprine on 9.8% of monitored days. Subjects were non-compliant with 6.8% of their cyclosporine doses and 9.8% of their azathioprine doses. Patients were compliant with both drugs on 86.6% of days and were non-compliant with both drugs on 5.1% of days. Subjects were non-compliant with cyclosporine during 5% and 13.2% of monitored days for once and twice daily dosing regimens, respectively. Concordance analysis demonstrated that for 91.7% of days of monitoring, compliance information was identical for both drugs. This study demonstrated the feasibility of electronic medication event monitoring among kidney transplant patients. This methodology represents an important tool for monitoring compliance of immunosuppressive agents essential to their safe and effective use, and should be considered for use in future studies of these drugs and others with substantial dose-dependent toxicity.

Journal Article↗
PubMed2005

Telephone self-monitoring among alcohol use disorder patients in early recovery: a randomized study of feasibility and measurement reactivity.

Frequent symptom self-monitoring protocols have become popular tools in the addiction field. Interactive Voice Response (IVR) is a telephone monitoring system that has been shown to be feasible for collecting frequent self-reports from a variety of research populations. Little is known, however, about the feasibility of using IVR monitoring in clinical samples, and few controlled trials exist assessing the impact of any type of frequent self-report monitoring on the behaviors monitored. This pilot study with patients in early recovery from an alcohol use disorder (n=98) evaluated compliance with two IVR monitoring protocols, subjective experiences with monitoring, and change in symptoms associated with monitoring (i.e., measurement reactivity). Participants were randomly assigned to call an IVR system daily for 28 days, once per week for 4 weeks, or only to complete 28-day follow-up assessment including retrospective drinking reports. Monitoring calls assessed alcohol craving, substance use, emotional well-being, and PTSD symptoms. Most monitoring participants completed calls on at least 75% of scheduled days (72.2% and 59.2% for daily and weekly, respectively). Including reconstructed data from follow-up of missed calls yielded 77.8% and 74.1% of maximum data points, respectively. Most monitoring participants indicated the protocol was manageable and reported positive or no effects of monitoring on urges to use alcohol, actual drinking, and PTSD symptoms. Analyses of measurement reactivity based on assessment one month after randomization found no significant group differences on drinking, craving for alcohol, or PTSD-related symptoms. Results suggest that IVR technology is feasible and appropriate for telephone symptom monitoring in similar clinical samples.

Aftercare↗
PubMed1998

The effect of imposed and self-selected computer monitor height on posture and gaze angle.

OBJECTIVE:: The objectives were to determine the postural consequences of varying computer monitor height and to describe self-selected monitor heights and postures. DESIGN:: The design involved experimental manipulation of computer monitor height, description of self-selected heights, and measurement of posture and gaze angles. BACKGROUND: Disagreement exists with regard to the appropriate height of computer monitors. It is known that users alter both head orientation and gaze angle in response to changes in monitor height; however the relative contribution of atlanto-occipital and cervical flexion to the change in head rotation is unknown. No information is available with regard to self-selected monitor heights. METHODS: Twelve students performed a tracking task with the monitor placed at three different heights. The subjects then completed eight trials in which monitor height was first self-selected. Sagittal postural and gaze angle data were determined by digitizing markers defining a two-dimensional three-link model of the trunk, cervical spine and head. RESULTS: The 27 degrees change in monitor height imposed was, on average, accommodated by 18 degrees of head inclination and a 9 degrees change in gaze angle relative to the head. The change in head inclination was achieved by a 6 degrees change in trunk inclination, a 4 degrees change in cervical flexion, and a 7 degrees change in atlanto-occipital flexion. The self-selected height varied depending on the initial monitor height and inclination. CONCLUSIONS: Self-selected monitor heights were lower than current 'eye-level' recommendations. Lower monitor heights are likely to reduce both visual and musculoskeletal discomfort. RELEVANCE: Musculoskeletal and visual discomfort may be reduced by placing computer monitors lower than currently recommended.

Journal Article↗
PubMed2006

Influence of broad-spectrum antibiotic prophylaxis on intracranial pressure monitor infections and subsequent infectious complications in head-injured patients.

BACKGROUND: The benefit of antibiotic prophylaxis for intracranial pressure (ICP) monitors remains controversial, and clinical practice varies widely. Whether any antibiotic coverage, particularly broad-spectrum coverage, reduces monitor-related infections remains unproved, and exposure to antibiotics may affect the susceptibility patterns of pathogens producing subsequent infectious complications. Despite the lack of data supporting its use, our level I trauma center had a long-standing ICP monitor prophylaxis protocol that provided broad-spectrum coverage that included ceftriaxone. In April 2002, a protocol change was instituted that substituted cefazolin for ceftriaxone as single-agent prophylaxis for ICP monitors. HYPOTHESIS: Broader-spectrum antibiotic prophylaxis does not reduce ICP monitor-related infections but is associated with acquisition of more drug-resistant infections than narrow-spectrum prophylaxis. METHODS: To evaluate the influence of broad- versus narrow-spectrum prophylaxis, a three year period encompassing each practice was selected. All injured patients with ICP monitors placed between January 1, 2001, and December 31, 2003 (n = 279), were identified using the Vanderbilt trauma database. Antibiotic prophylaxis for ICP monitors was determined using the hospital financial database to identify all antibiotics given to individual patients and subsequent chart review to identify those antibiotics given solely for ICP prophylaxis. A total of 119 patients received narrow-spectrum (either cefazolin or vancomycin; n = 100) or no (n = 19) prophylaxis, whereas 160 received broad-spectrum prophylaxis (ceftriaxone or ciprofloxacin). The two groups did not differ with respect to baseline demographics, type of ICP monitor, or duration of monitor placement. Infectious complications were determined by continuous infection surveillance utilizing standard U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance System (CDC-NNIS) definitions and maintained in a contemporary database. The influence of broad-spectrum antibiotic prophylaxis on both ICP monitor infections and subsequent infections outside the central nervous system (CNS) was determined. RESULTS: Nine patients (3.2%) developed CNS infections; two of 119 patients (1.7%) who received narrow-spectrum or no prophylaxis versus seven of 160 patients (4.4%) who received broad-spectrum prophylaxis (p = NS). Only the duration of monitor placement and Injury Severity Score were associated with the infection rate. In the total population, 185 infections occurred in 93 patients (33%). Infection rates did not differ between patients who received narrow-spectrum or no prophylaxis (32%) and those who received broad-spectrum prophylaxis (34%). However, patients who received broad-spectrum prophylaxis acquired gram-negative infections with significantly greater antibiotic resistance. CONCLUSIONS: Broad-spectrum antibiotic prophylaxis of ICP monitors does not reduce CNS infections, but is associated with a shift to resistant gram-negative pathogens in subsequent infectious complications. Thus, broad-spectrum antibiotic prophylaxis of ICP monitors should be eliminated or minimized unless data from randomized trials prove its utility.

Adult↗
PubMed2006

Gender, alcohol consumption, and parental monitoring.

The authors examined the relationships among gender, alcohol consumption, and parental monitoring, including television monitoring. Student volunteers (N = 150; 90% Caucasian, 79% women) participated by reporting retrospective general parental monitoring, television monitoring, and recent drinking behaviors. On the basis of the retrospective reports by the participants, when they were growing up the men received less overall parental monitoring but not less television monitoring than the women. Women's drinking quantity was correlated with parental monitoring, whereas men's drinking frequency was associated with both parental monitoring and television monitoring. Interestingly, men's binge drinking frequency was correlated with television monitoring but not with overall parental monitoring, whereas women's binge drinking frequency was correlated with overall parental monitoring but not with television monitoring. Implications for preventing alcohol misuse and ideas for future research are discussed.

Adolescent↗
PubMed2003

Towards efficient guidelines: how to monitor guideline use in primary care.

OBJECTIVES: To develop a model for using routine data monitoring in the evaluation of clinical guideline usage in primary healthcare settings. DESIGN: A monitoring framework was developed following a number of semistructured interviews with potential users. These data informed a postal survey among a random sample of primary healthcare professionals. Then to test out the framework, a further semistructured interview study was used to explore the practical issues relating to monitoring guideline use. Case studies were then undertaken to investigate the use of evidence-based review criteria and patient-centred outcome measures as methods for providing monitoring information. A case study in one general practice used interviews to examine the possible costs associated with guideline-use monitoring. SETTING AND PARTICIPANTS: Interviews were undertaken with primary care professionals from one local health community. The postal survey was undertaken among staff from a purposive sample of Health Authorities in England and a random sample of general practitioners and practice nurses from the selected Health Authority areas. The second phase involved interviews with Health Authority, Primary Care Group and general practice staff from three Health Authority areas. Case studies were undertaken in volunteer general practices and among patients who consented to provide confidential health outcome information. RESULTS: Interviewees recognised some value in guideline-use monitoring, however they were concerned about the practicalities from two perspectives. First, although primary care computing systems were to be found in most general practices, the technology for monitoring was absent in many practices. Training in these skills would be required before monitoring of guideline use could be a practical reality. Second, there were clear signals of a more general lack of interest or awareness in the subject of continuous review of care. This, together with a feeling of being overloaded with new initiatives, meant that implementation of a monitoring framework could be problematic and might need considerable support in order to make progress. CONCLUSIONS: Effective methods can be developed for monitoring guideline use in primary care. However there is a need to address the degree of understanding that many primary healthcare professionals have of the concepts and practical issues in the area of guideline-use monitoring, and of expectations of this within the NHS. In addition there are a number of technical issues concerned with efficient capture of clinical information and its evaluation. Further research is recommended in the following areas: the extent to which patient concordance with the guideline recommendations be taken into account in the assessment of clinician conformance with guideline recommendations; the costs and benefits to patient care of guideline-use monitoring; the most efficient methods of developing valid and reliable review criteria which are policy and evidence (guidelines) based; whether review criteria are more useful than guidelines in improving quality of care; what additional benefits to patient care can offered by monitoring patient-centred health outcomes in addition to process of care, and at what cost?

Guideline Adherence↗
PubMed2006

Different effects of ambulatory blood pressure monitoring on subjective and objective sleep quality.

OBJECTIVE: To determine whether ambulatory blood pressure monitoring affects objective and subjective sleep quality in patients tested at home. METHODS: Seventy consecutive patients (40 women and 30 men, aged 53+/-15 years), having ambulatory blood pressure monitoring to monitor the efficacy of antihypertensive treatment or to distinguish between hypertension or white-coat hypertension had an evaluation of their sleep quality on a first night with ambulatory blood pressure monitoring and the three following nights without ambulatory blood pressure monitoring. Ambulatory blood pressure monitoring was performed with an auscultatory device with a measure every 15 min during 24 h. Sleep evaluation criteria were both subjective (sleep quality score and sleep questionnaire) and objective (wrist actigraphy monitoring). Sleep parameters during night 1 with ambulatory blood pressure monitoring were compared with those during night 4 without ambulatory blood pressure monitoring. Usual quality of sleep of the patients was assessed by the mean sleep quality score over 7 consecutive days. RESULTS: The sleep quality score was significantly higher for night 4 than for night 1 (7.3+/-2.1 vs. 5.3+/-2.3; P<0.0001). In contrast, actigraphy parameters (actual sleep time, mean activity score, and fragmentation index) were similar on night 1 and night 4 (6.7+/-1.2 vs. 6.9+/-1.2, 13.2+/-9.8 vs. 12.1+/-8.4, and 31.0+/-14.5 vs. 29.9+/-14.3, respectively). Subjective sleep quality was significantly altered by ambulatory blood pressure monitoring in good sleepers (mean sleep quality score > or =7, 73% of patients) but not in poor sleepers. The effect of ambulatory blood pressure monitoring on subjective sleep quality did not differ between dippers and nondippers. CONCLUSIONS: Objective sleep quality as assessed by wrist actigraphy is not significantly altered by ambulatory blood pressure monitoring, whereas subjective sleep quality is adversely affected in good sleepers.

Adolescent↗
PubMed1996

Inclusion of supine period in short-duration pH monitoring is essential in diagnosis of gastroesophageal reflux disease.

Prolonged esophageal pH monitoring is the most accurate method for detecting abnormal gastroesophageal reflux (GER) in patients with gastroesophageal reflux disease (GERD). However, some investigators have found that short-duration postprandial pH monitoring in the upright position is also useful, while others have failed to find such results. Therefore, we have compared a 6-hr period of pH monitoring (3-hr postprandial period after daytime meal and 3-hr supine period) with a total 24-hr period in detecting abnormal gastroesophageal reflux. Sixty-five patients (44 men, mean age 41.3 years) with GERD and 16 healthy volunteers (11 men, mean age 34.3 years) underwent 24-hr pH monitoring according to a standard protocol. Various reflux parameters during 24-hr pH monitoring were compared with reflux parameters during the 6-hr period. Abnormal GER was detected in 56 patients presenting with typical symptoms of GERD (sensitivity 86.2%). These patients could be further divided into upright (N = 18), supine (N = 15), and combined (N = 23) refluxers, depending on the posture in which abnormal reflux occurred. Esophageal pH monitoring during the 3-hr postprandial upright period showed abnormal reflux in only 35 patients (sensitivity 53.8%; P < 0.00005, compared with the 24-hr pH monitoring period). Abnormal GER was identified in 13 of 18 upright, 19 of 23 combined, and only one of 15 supine refluxers, as well as in two of nine patients with normal 24-hr pH-metry. However, inclusion of the 3-hr supine monitoring period in the 3-hr postprandial upright period improved detection of abnormal GER to 78.5% (51 patients; P = NS compared with 24-hr pH monitoring period). This was related mainly to improved detection of abnormal GER in supine refluxers (11 of 15; 73.3%). Esophageal acid exposure time correlated significantly with severity of esophagitis only during the total and supine periods of both the 24- and 6-hr periods and not during the upright period. Esophageal acid clearance correlated significantly with increasing grades of esophagitis for the supine and total periods only. We conclude that 3-hr postprandial pH monitoring, as has been conventionally practiced, is not appropriate in the detection of abnormal GER; inclusion of a supine period in the short-duration pH monitoring schedule increases the detection of pathological reflux. We therefore recommend that a supine period should be included in short-duration pH monitoring schedules. We also found that supine reflex was the most important factor in the development of esophagitis.

Adult↗
PubMed2005

Cerebral monitoring in the operating room and the intensive care unit: an introductory for the clinician and a guide for the novice wanting to open a window to the brain. Part I: The electroencephalogram.

While there is an increasing body of knowledge in regard to central nervous system function and/or the mode of action of centrally active agents on neuronal function, little is done to develop new techniques on how to measure such changes. Also, monitoring of the cardiovascular system in the past has made extensive progress especially when it comes to evaluate the failing heart. In contrast monitoring of the central nervous system is only done in rare cases where operative procedures likely impede nervous function integrity. Since in the past decade the aging population undergoing operation has rise considerably, the risk of cerebral malperfusion or minute signs of degradation of the aging central nervous system (CNS) to anesthetics and agents being used in the operation room (OR) or the intensive care unit (ICU), needs continuous monitoring of an organ which presents the highest vulnerability and is likely to deteriorate faster than the cardiovascular system. In spite the rapid improvement in technology regarding the electroencephalogram (EEG) and evoked potential monitoring, physicians still are reluctant to use a technology on a routine base, which will give them insight information into brain function and activity. Such "windows to the brain" now not just are reserved to specialists working in the area of neurology and/or psychiatry. More so, cerebral monitoring is getting an integrated part in the overall therapy in patients undergoing operation or who need ventilatory support in the ICU as it effects the well-being and the outcome. The present book therefore, is intended for the practitioners who work with the patient, guide the clinician in his decision making and outlining those situations where cerebral monitoring presents an integrated part in the diagnosis and therapy of patient care. Without going too much into the technical details, representative cases underline the potential use of cerebral monitoring in the underlying clinical situation where either the patient presents borderline perfusion of the CNS, undergoes vascular surgery, or where monitoring of cerebral function in the intensive care in a head trauma patients is an integrated part in therapy. The book therefore is meant for all those clinicians who have to deal with the CNS in a day-to-day situation. This may be the anesthesiologist, the surgeon, the intensive care therapist, the nurse anesthetist as well as all other medical personal involved in intensive care therapy. The aim of the book therefore is to outline the possibilities, the limitations, and the options for therapy when the windows to the brain are opened, how to interpret the data in the light of other physiological parameters and aid the user in the technical details of how to avoid artifacts in recording which may have an impact on final decision making. Therefore, emphasis is placed on the electrode placement, artifact and electrical noise reduction, as well as data interpretation so that cerebral function diagnosis can be made on reliable grounds. The following serves as an introduction to and as a reference guide for Cerebral Monitoring in the OR and the ICU: Gives complete coverage of EEG power spectra analysis. Describes in detail the EEG machines available to be used in the OR and ICU setting. Describes in detail the major features of EEG power spectra and evoked potential measurements, including amplifiers, filter setting and microprocessor algorithm for data reduction. Gives suggestions for assessing and improving signal quality, including noise and artifact rejection, which usually are encountered in the operation room and the intensive care unit, both of which can be considered as electrically contaminated. Gives examples of EEG power spectra and evoked potential monitoring related to different types of anesthesia, in coma, after head trauma, and for the detection of ischemic events. In addition, gives complete coverage of those machines being available for the OR and the ICU, including a list of parameters regarding latency and amplitude in evoked potential As an introductory, recommendations are given for the novice to start cerebral monitoring and guide the beginner in setting up cerebral monitoring in the clinical environment.

Artifacts↗
PubMed1986

The indirectly obtained fetal heart rate: comparison of first- and second-generation electronic fetal monitors.

Fetal heart rate variability has become an essential component in evaluation of the fetus during continuous electronic fetal monitoring. Because of technical deficiencies of monitoring equipment, fetal heart rate variability may not always be available, such as during indirect monitoring of the fetus. In lieu of integration, a mathematical procedure called autocorrelation has, with the use of microprocessors, been incorporated into the fetal monitor, creating the "second generation" of electronic fetal monitoring. This study examined the accuracy of the first- and second-generation monitors by comparing simultaneously obtained indirect and direct real-time fetal heart rate data. The second-generation monitor produced an indirectly obtained fetal heart rate that was more accurate when compared with the directly obtained data than that with the first-generation fetal monitor. In addition, the variation in data from the first-generation monitor was substantially higher than that with the second-generation monitor. It is concluded that the fetal heart rate tracing from the second-generation monitor is more accurate when compared with the fetal electrocardiogram and may facilitate a truer interpretation of fetal heart rate variability than that obtained with the first-generation monitor.

Electrocardiography↗
PubMed1994

Prolonged cardiorespiratory monitoring of children more than twelve months of age: characterization of events and approach to discontinuation.

We assessed children referred to our apnea program who were > or = 12 months of age, beyond the at-risk period for sudden infant death syndrome (SIDS), but for whom home cardiorespiratory monitoring had continued. Our objectives were to (1) determine reasons for initiation and continuation of monitoring, (2) apply documented monitoring of transthoracic impedance, electrocardiographic signals, and, in a subset of patients, pulse oximetry, to determine the types of cardiorespiratory events that these children experienced, and (3) describe how documented monitoring was applied for eventual discontinuation of monitoring. Among 45 patients (median age, 22 months), 263 disks were collected, representing 2982 monitor days. Indications for initiation of monitoring included an apparent life-threatening event in 51.1% of patients, apnea of prematurity in 35.5%, history of SIDS or apparent life-threatening event in a relative in 9%, and intrauterine drug exposure in 4.4%. Continuation of monitoring had been based on continued alarms and, in 31% of patients, documented apnea, bradycardia, or hemoglobin desaturation. In 40 of 45 patients, 2292 episodes of apnea (17.5% of all events) were recorded (range, 16 to 31 seconds). Five patients had 223 episodes of bradycardia (1.7% of all events). Of all 13,075 recorded events, 76.8% resulted in audible alarms, but only 3.9% of these alarms were for apnea and 2.2% were for bradycardia. Of 19 patients studied with pulse oximetry, 18 had 663 episodes of hemoglobin desaturation <90%. All children were thriving at the time of referral. Discontinuation of monitoring was based on a child's ability to resume breathing spontaneously or on normalization of heart rate or hemoglobin saturation before the audible alarm sounded, for a minimum of 2 to 3 months. By extension of the audible apnea alarm to 25 or 30 seconds, lowering of the cutoff point for bradycardia alarm, or lowering of the cutoff point for the oximetry alarm, a recommendation to discontinue monitoring could be made for 41 patients. Of these, no child had a recurrence of cardiorespiratory events or died of SIDS. Documented monitoring proved to be a useful clinical tool for investigation of the clinical and physiologic importance of these cardiorespiratory events in children beyond the at-risk period for SIDS; recommendations about discontinuation of monitoring could be made knowledgeably and safely.

Adolescent↗
PubMed1993

Effect of intermittent versus continuous patient monitoring on reliability indices during automated perimetry.

PURPOSE: This prospective, randomized study was undertaken to determine the effect of intermittent versus continuous patient monitoring on reliability indices (fixation losses, false-positive errors, and false-negative errors) during automated static perimetry. METHODS: A practice Humphrey Program C30-2 visual field was administered to 169 subjects (mean age +/- standard deviation, 56 +/- 18 years) for 1.5 minutes, during which time trained technicians continuously monitored all subjects and assessed patient fixation as noted on the eye monitor. The computer-generated reliability indices during the 1.5 minute practice test were recorded. After completion of the practice test, the 169 eyes were randomized to either intermittent or continuous monitor for the permanent C30-2 test. During intermittent monitoring, the technician returned periodically to the examination room to assess the subject's performance. For continuous monitoring, the technician continually assessed the subject's performance while remaining in the examination room throughout the test duration. RESULTS: The mean number of visits per visual field test during intermittent monitoring was 4.0, and mean test duration was 15.8 minutes. There was no difference in the mean deviation, pattern standard deviation, and short-term fluctuation (P = 0.85, 0.98, and 0.41, respectively) of the visual fields for intermittent and continuous monitoring, suggesting similar diffuse depression and localized defects in the visual fields for each group. The mean fixation losses (6.9%), false-positive errors (1.8%), and false-negative errors (5.8%) for the intermittently monitored group were not different from the mean fixation losses (7.8%), false-positive errors, (3.1%) and false-negative errors (5.0%) for the continuously monitored group (P = 0.40, 0.24, and 0.36, respectively). CONCLUSION: Although recommended, continuous monitoring does not appear necessary for all patients undergoing automated perimetry. Error-free reliability indices combined with the technician's judgment of patient reliability during the first 1.5 minutes of C30-2 testing may be a guideline for choosing intermittent monitoring.

Adult↗