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Journal: Journal of clinical monitoring and computing


The article Is the new ASNM intraoperative neuromonitoring supervision “guideline” a trustworthy guideline? A commentary, written by Stanley A. Skinner, Elif Ilgaz Aydinlar, Lawrence F. Borges, Bob S. Carter, Bradford L. Currier, Vedran Deletis, Charles Dong, John Paul Dormans, Gea Drost, Isabel Fernandez‑Conejero, E. Matthew Hoffman, Robert N. Holdefer, Paulo Andre Teixeira Kimaid, Antoun Koht, Karl F. Kothbauer, David B. MacDonald, John J. McAuliffe III, David E. Morledge, Susan H. Morris, Jonathan Norton, Klaus Novak, Kyung Seok Park, Joseph H. Perra, Julian Prell, David M. Rippe, Francesco Sala, Daniel M. Schwartz, Martín J. Segura, Kathleen Seidel, Christoph Seubert, Mirela V. Simon, Francisco Soto, Jeffrey A. Strommen, Andrea Szelenyi, Armando Tello, Sedat Ulkatan, Javier Urriza and Marshall Wilkinson, was originally published electronically on the publisher’s internet portal (currently SpringerLink) on 05 January 2019 without open access. With the author(s)‘ decision to opt for Open Choice the copyright of the article changed on 30 January 2019 to © The Author(s) 2019 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The original article has been corrected.


Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I-II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I-II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.


Supplemental oxygen is administered in the vast majority of patients in the perioperative setting and in the intensive care unit to prevent the potentially deleterious effects of hypoxia. On the other hand, the administration of high concentrations of oxygen may induce hyperoxia that may also be associated with significant complications. Oxygen therapy should therefore be precisely titrated and accurately monitored. Although pulse oximetry has become an indispensable monitoring technology to detect hypoxemia, its value in assessing the oxygenation status beyond the range of maximal arterial oxygen saturation (SpO2 ≥97%) is very limited. In this hyperoxic range, we need to rely on blood gas analysis, which is intermittent, invasive and sometimes delayed. The oxygen reserve index (ORI) is a new continuous non-invasive variable that is provided by the new generation of pulse oximeters that use multi-wavelength pulse co-oximetry. The ORI is a dimensionless index that reflects oxygenation in the moderate hyperoxic range (PaO2 100-200 mmHg). The ORI may provide an early alarm when oxygenation deteriorates well before any changes in SpO2 occur, may reflect the response to oxygen administration (e.g., pre-oxygenation), and may facilitate oxygen titration and prevent unintended hyperoxia. In this review we describe this new variable, summarize available data and preliminary experience, and discuss its potential clinical utilities in the perioperative and intensive care settings.

Concepts: Oxygen, Hypoxia, Arterial blood gas, Pulse oximetry, Oxygen saturation, Oxygen therapy, Oxygen sensor, Pulse oximeter


The genesis of cardiogenic oscillations, i.e. the small waves in airway pressure (COS(paw)) and flow (COS(flow)) signals recorded at the airway opening is under debate. We hypothesized that these waves are originated from cyclic changes in pulmonary artery (PA) pressure and flow but not from the physical transmission of heartbeats onto the lungs. The aim of this study was to test this hypothesis. In 10 anesthetized pigs, COS were evaluated during expiratory breath-holds at baseline with intact chest and during open chest conditions at: (1) close contact between heart and lungs; (2) no heart-lungs contact by lifting the heart apex outside the thoracic cavity; (3) PA clamping at the main trunk during 10 s; and (4) during manual massage after cardiac arrest maintaining the heart apex outside the thorax, with and without PA clamping. Baseline COS(paw) and COS(flow) amplitude were 0.70 ± 0.08 cmH(2)O and 0.51 ± 0.06 L/min, respectively. Both COS amplitude decreased during open chest conditions in step 1 and 2 (p < 0.05). However, COS(paw) and COS(flow) amplitude did not depend on whether the heart was in contact or isolated from the surrounding lung parenchyma. COS(paw) and COS(flow) disappeared when pulmonary blood flow was stopped after clamping PA in all animals. Manual heart massages reproduced COS but they disappeared when PA was clamped during this maneuver. The transmission of PA pulsatilty across the lungs generates COS(paw) and COS(flow) measured at the airway opening. This information has potential applications for respiratory monitoring.

Concepts: Blood, Lung, Heart, Chest, Vein, Pulmonary artery, Thorax, Thoracic cavity


Esophageal stethoscope is less invasive and easy to handling. And it gives a lot of information. The purpose of this study is to investigate the correlation of blood pressure and heart sound as measured by esophageal stethoscope. Four male beagles weighing 10 to 12 kg were selected as experimental subjects. After general anesthesia, the esophageal stethoscope was inserted. After connecting the microphone, the heart sounds were visualized and recorded through a self-developed equipment and program. The amplitudes of S1 and S2 were monitored real-time to examine changes as the blood pressure increased and decreased. The relationship between the ratios of S1 to S2 (S1/S2) and changes in blood pressure due to ephedrine was evaluated. The same experiment was performed with different concentration of isoflurane. From S1 and S2 in the inotropics experiment, a high correlation appeared with change in blood pressure in S1. The relationship between S1/S2 and change in blood pressure showed a positive correlation in each experimental subject. In the volatile anesthetics experiment, the heart sounds decreased as MAC increased. Heart sounds were analyzed successfully with the esophageal stethoscope through the self-developed program and equipment. A proportional change in heart sounds was confirmed when blood pressure was changed using inotropics or volatile anesthetics. The esophageal stethoscope can achieve the closest proximity to the heart to hear sounds in a non-invasive manner.

Concepts: Artery, Anesthesia, Change, Cardiac cycle, Heart sounds, Auscultation, Stethoscope, Microphone


The current standard of care for patients suffering from acute respiratory distress syndrome (ARDS) is ventilation with a tidal volume of 6 ml/kg predicted body weight (PBW), but variability remains in the tidal volumes that are actually used. This study aims to identify patient scenarios for which there is discordance between physicians in choice of tidal volume and positive end-expiratory pressure (PEEP) in ARDS patients. We developed an algorithm based on fuzzy logic for encapsulating the expertise of individual physicians regarding their use of tidal volume and PEEP in ARDS patients. The algorithm uses three input measurements: (1) peak airway pressure (PAP), (2) PEEP, and (3) arterial oxygen saturation (SaO2). It then generates two output parameters: (1) the deviation of tidal volume from 6 ml/kg PBW, and (2) the change in PEEP from its current value. We captured 6 realizations of intensivist expertise in this algorithm and assessed their degree of concordance using a Monte Carlo simulation. Variability in the tidal volume recommended by the algorithm increased for PAP > 30 cmH2O and PEEP > 5 cmH2O. Tidal volume variability decreased for SaO2 > 90 %. Variability in the recommended change in PEEP increased for PEEP > 5 cmH2O and for SaO2 near 90 %. Intensivists vary in their management of ARDS patients when peak airway pressures and PEEP are high, suggesting that the current goal of 6 ml/kg PBW may need to be revisited under these conditions.

Concepts: Medicine, Pulmonology, Intensive care medicine, Acute respiratory distress syndrome, Mechanical ventilation, Physician, Thermodynamics, Pressure


Sleep apnea (SA) is a very common disease with serious health consequences, yet is very under-diagnosed, partially because of the high cost and limited accessibility of in-laboratory polysomnography (PSG). The purpose of this work is to introduce a newly developed portable system for the diagnosis of SA at home that is both reliable and easy to use. The system includes personal devices for recording breath sounds and airflow during sleep and diagnostic algorithms to process the recorded data. The data capturing device consists of a wearable face frame with an embedded electronic module featuring a unidirectional microphone, a differential microphone preamplifier, a microcontroller with an onboard differential analogue to digital converter, and a microSD memory card. The device provides continuous data capturing for 8 h. Upon completion of the recording session, the memory card is returned to a location for acoustic analysis. We recruited 49 subjects who used the device independently at home, after which each subject answered a usability questionnaire. Random data samples were selected to measure the signal-to-noise ratio (SNR) as a gauge of hardware functionality. A subset of 11 subjects used the device on 2 different nights and their results were compared to examine diagnostic reproducibility. Independent of those, system’s performance was evaluated against PSG in the lab environment in 32 subject. The overall success rate of applying the device in un-attended settings was 94 % and the overall rating for ease-of-use was ‘excellent’. Signal examination showed excellent capturing of breath sounds with an average SNR of 31.7 dB. Nine of the 11 (82 %) subjects had equivalent results on both nights, which is consistent with reported inter-night variability. The system showed 96 % correlation with simultaneously performed in-lab PSG. Conclusion: Our results suggest excellent usability and performance of this system and provide a strong rationale to further improve it and test its robustness in a larger study.

Concepts: Sleep, Recording, Sleep apnea, Signal-to-noise ratio, Microphone, Analog-to-digital converter, MicroSD, Preamplifier


The purpose of this study was to introduce clinical decision support (CDS) that exceeds conventional alerting at tertiary care intensive care units. We investigated physicians' functional CDS requirements in periodic interviews, and analyzed technical interfaces of the existing commercial patient data management system (PDMS). Building on these assessments, we adapted a platform that processes Arden Syntax medical logic modules (MLMs). Clinicians demanded data-driven, user-driven and time-driven execution of MLMs, as well as multiple presentation formats such as tables and graphics. The used PDMS represented a black box insofar as it did not provide standardized interfaces for event notification and external access to patient data; enabling CDS thus required periodically exporting datasets for making them accessible to the invoked Arden engine. A client-server-architecture with a simple browser-based viewer allows users to activate MLM execution and to access CDS results, while an MLM library generates hypertext for diverse presentation targets. The workaround that involves a periodic data replication entails a trade-off between the necessary computational resources and a delay of generated alert messages. Web technologies proved serviceable for reconciling Arden-based CDS functions with alternative presentation formats, including tables, text formatting, graphical outputs, as well as list-based overviews of data from several patients that the native PDMS did not support.

Concepts: Medicine, Intensive care medicine, Data, Decision theory, Computer, Medical informatics, Medical logic module, Arden syntax


The aim of this paper is to compare baroreflex sensitivity (BRS) following anesthesia induction via propofol to pre-induction baseline values through a systematic and mathematically robust analysis. Several mathematical methods for BRS quantification were applied to pre-operative and intra-operative data collected from patients undergoing major surgery, in order to track the trend in BRS variations following anesthesia induction, as well as following the onset of mechanical ventilation. Finally, a comparison of BRS trends in chronic hypertensive patients (CH) with respect to non hypertensive (NH) patients was performed. 10 NH and 7 CH patients undergoing major surgery with American Society of Anesthesiologists classification score 2.5 ± 0.5 and 2.6 ± 0.5 respectively, were enrolled in the study. A Granger causality test was carried out to verify the causal relationship between RR interval duration and systolic blood pressure (SBP), and four different mathematical methods were used to estimate the BRS: (1) ratio between autospectra of RR and SBP, (2) transfer function, (3) sequence method and (4) bivariate closed loop model. Three different surgical epochs were considered: baseline, anesthetic procedure and post-intubation. In NH patients, propofol administration caused a decrease in arterial blood pressure (ABP), due to its vasodilatory effects, and a reduction of BRS, while heart rate (HR) remained unaltered with respect to baseline values before induction. A larger decrease in ABP was observed in CH patients when compared to NH patients, whereas HR remained unaltered and BRS was found to be lower than in the NH group at baseline, with no significant changes in the following epochs when compared to baseline. To our knowledge, this is the first study in which the autonomic response to propofol induction in CH and NH patients was compared. The analysis of BRS through a mathematically rigorous procedure in the perioperative period could result in the availability of additional information to guide therapy and anesthesia in uncontrolled hypertensive patients, which are prone to a higher rate of hypotension events occurring during general anesthesia induction.

Concepts: Causality, Hypertension, Blood pressure, Artery, Anesthesia, Orthostatic hypotension, Hypotension, Granger causality


Pressure-transducer kits have frequency characteristics such as natural frequency and damping coefficient, which affect the monitoring accuracy. The aim of the present study was to investigate the effect of planecta ports and a damping device (ROSE™, Argon Medical Devices, TX, USA) on the frequency characteristics of pressure-transducer kits. The FloTrac sensor kit (Edwards Lifesciences, CA, USA) and the DTXplus transducer kit (Argon Medical Devices) were prepared with planecta ports, and their frequency characteristics were tested with or without ROSE™. The natural frequency and damping coefficient of each kit were obtained using frequency characteristics analysis software and evaluated by plotting them on the Gardner’s chart. By inserting a planecta port, the natural frequency markedly decreased in both the FloTrac sensor kit (from 40 to 22 Hz) and the DTXplus transducer kit (from 35 to 22 Hz). In both kits with one planecta port, the damping coefficient markedly increased by insertion of ROSE™ from 0.2 to 0.5, optimising frequency characteristics. In both kits with two planecta ports, however, the natural frequency decreased from 22 to 12 Hz. The damping coefficient increased from 0.2 to 0.8 by insertion of ROSE™; however, optimisation was not achieved even by ROSE™ insertion. Planecta ports decrease the natural frequency of the kit. ROSE™ is useful to optimise the frequency characteristics in the kits without or with one planecta port. However, optimisation is difficult with two or more planecta ports, even with the ROSE™ device.

Concepts: Device, Resonance, Vibration, Damping, Edwards Lifesciences