Simple approaches to difficult

topics
Measurement and Monitoring
Dr Alan McLintic
Middlemore Hospital

Q: How do you measure Cardiac output using
thermodilution?
Q: How do you measure Cardiac output using
thermodilution?
Summary
Thermodilution principle is a modification of the Fick principle


flow blood difference ation AVconcentr organ by up taken substance Amt. =
Q: How do you measure Cardiac output using
thermodilution?
Summary
Thermodilution principle is a modification of the Fick principle


1
.
1 -
1
.
l.min 5
10
ml.dl 15 20
ml.min 250

=
Q
Q
difference ation AVconcentr
organ by up en Amount tak
organ through flow Blood =
Q: How do you measure Cardiac output using
thermodilution?
Summary
Pulmonary artery catheter (Swan-Ganz catheter)


Thermistor
Balloon
Proximal
lumen
Distal lumen
Connection
for thermistor
Q: How do you measure Cardiac output using
thermodilution?
Summary
Inserted through large neck vein


Q: How do you measure Cardiac output using
thermodilution?
Summary
Floated through heart until the tip is in the pulmonary artery


Q: How do you measure Cardiac output using
thermodilution?
10 ml dextrose (21C)
Dilution of coldness
measured here
Q: How do you measure Cardiac output using
thermodilution?
C
o
l
d
e
r

Time
Recirculation
Body temperature
Q: How do you measure Cardiac output using
thermodilution?
C
o
l
d
e
r

Time
The greater the cardiac output, faster the
dilution, the smaller the Area Under the Curve
(AUC)
C
o
l
d
e
r

Time
High
cardiac
output
Lower
cardiac
output
Q: How do you measure Cardiac output using
thermodilution?
Dye dilution:
(g/l) ion concentrat Mean
(g) added dye Mass
Volume =
Mass of dye (g)
Mean concentration dye (g)
Q: How do you measure Cardiac output using
thermodilution?
C
o
n
c
e
n
t
r
a
t
i
o
n

d
y
e

(
g
/
l
)

Time
Dyes:
(g/l.min) AUC
(g) added dye Mass
.
= Q
Q: How do you measure Cardiac output using
thermodilution?
C
o
l
d
e
r

Time
Thermodilution
AUC
added cold Mass
.
= Q
Body temperature
Q: How do you measure Cardiac output using
thermodilution?
C
o
l
d
e
r

Time
Thermodilution
( )
AUC
. T T Volume.
AUC
added cold Mass
Inj ectate Body
.
k
Q

= =
Body temperature
Q: How do you measure Cardiac output using
thermodilution?
C
o
l
d
e
r

Time
Thermodilution
( )
}

= =
0
B
Inj ectate Body
.
) ( T
. T T Volume.
AUC
added cold Mass
dt t
k
Q
Body temperature
Modified Stewart-Hamilton
equation
Q: How do you measure Cardiac output using
thermodilution?
C
o
l
d
e
r

Time
Thermodilution
AUC
added cold Mass
.
= Q
Body temperature
Q: How do you measure FRC using a Body
Plethysmograph?
Q: How do you measure FRC using a Body
Plethysmograph?
The Body Plethysmograph is
a method to measure lung
volumes by the application of
Boyles Law
Q: How do you measure FRC using a Body
Plethysmograph?
Box pressure
Shutter
Mouth pressure
Calibrating syringe
Step1.
Calibrate changes in
box pressure as
changes in volume of
air in the box
Q: How do you measure FRC using a Body
Plethysmograph?
Box
volume
Q: How do you measure FRC using a Body
Plethysmograph?
Step2.
Apply Boyles Law to
lung air.
while panting against
closed shutter


Box
volume
Q: How do you measure FRC using a Body
Plethysmograph?
Step2.
Apply Boyles Law to
lung air.


Box
volume
P
Bar
. V
FRC
= (P
Bar
- AP). (V
FRC
+ AV)
Q: How do you measure FRC using a Body
Plethysmograph?
Step2.



Atmospheric
pressure: 100 kPa
FRC? Mouth pressure when
shutter closed
FRC? A Box volume
P
Bar
. V
FRC
= (P
Bar
- AP). (V
FRC
+ AV)
Box
volume
Q: How do you measure FRC using a Body
Plethysmograph?
Summary
Method of measuring lung volumes by the application of Boyles
law
Briefly explain set up and calibration of box pressure for box air
volume
Write equation


Atmospheric
pressure: 100 kPa
FRC? Mouth pressure when
shutter closed
FRC? A Box volume
Summary:
P
Bar
. V
FRC
= (P
Bar
- AP). (V
FRC
+ AV)
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?


Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?


Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?


Full answer regarding accuracy
Practical aspects
Prevention clot, kinking, choice of artery, cannulae
Zeroing
Static accuracy
Dynamic accuracy

Natural
frequency (F
N
)
Damping
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
Tendency for a system to
resist oscillation through
friction
Frequency at which a
system oscillates most
freely
Natural
frequency (F
N
)
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
Frequency at which a
system oscillates most
freely
The F
N
is the same frequency as the
upstroke of trace resonance and
overshoot
Natural
frequency
High as
possible
Prevents resonance from
biological signals
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
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4
HR
F
N
Short, stiff, short, wide tubing
Small stiff transducer
Low density fluid
Natural
frequency
Damping
High as
possible
Optimal
Prevents resonance from
biological signals
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
Undamped
D = 0
Underdamped
D = ~ 0.3
Optimal
D = 0.64
Critical
D = 1.0
In a totally undamped
system the system
would oscillate at the
undamped natural
frequency without any
decrease in amplitude
In an underdamped
system, overshoot is
common and the
system oscillates at the
Fn with progressively
diminishing amplitude.
This system would
result in distortion and
over-reading from
overshoot
In an optimally
damped system,
there is only 7 %
overshoot. Ideal
compromise
between minimal
overshoot and
response speed
In a critically
damped system,
damping has
increased to the
point where
overshoot is just
avoided. The
response speed of
this system would
be too slow
7% overshoot in fast flush test
Natural
frequency
Damping
High as
possible
Optimal
Prevents resonance from
biological signals
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
D = 0.64
Short, stiff, short, wide tubing
Small stiff transducer
High density fluid
Natural
frequency
Damping
High as
possible
Optimal
Prevents resonance from
biological signals
To produce flat
frequency response
Prevent phase distortion
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
Prevents amplitude distortion of
high frequency waveforms
All elements of the waveform are
delayed by the same time interval
To produce flat
frequency response
Arterial waveforms are made
up of several different sine
waves of different frequencies
Fourier analysis
To produce flat
frequency response
Frequency of sine waves
A
m
p
l
i
t
u
d
e

r
e
l
a
t
i
v
e

t
o

c
o
r
r
e
c
t

a
m
p
l
i
t
u
d
e

1.0
Ideal
Very under-damped
(0.1)
F
N
Optimal damping (0.64)
Flat frequency response to 2/3 F
N
All but the very
fastest
waveforms will be
reproduced
without amplitude
distortion
T
o
o

b
i
g

T
o
o

s
m
a
l
l

Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
Natural
frequency
Damping
High as
possible
Optimal
Prevents resonance from
biological signals
To produce flat
frequency response
Prevent phase distortion
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
Prevents amplitude distortion of
high frequency waveforms
All elements of the waveform are
delayed by the same time interval
Prevent phase distortion
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
All elements of the waveform are
delayed by the same time interval

If the same time delay is applied
to both component waveforms, the
1 Hz waveform will be delayed by
90 and the 2 Hz waveform by
180. Thus the phase delay would
be proportional to the frequency.
This will only occur if damping is
optimal.
Time
delay
90
180
Natural
frequency
Damping
High as
possible
Optimal
Prevents resonance from
biological signals
To produce flat
frequency response
Prevent phase distortion
Q: What are the important physical principles in
the design of an invasive pressure monitoring
system?
D = 0.64
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4
HR
F
N
Q: How does BIS analyse EEG?
Clinical levels
of anaesthesia
scored
Statistically
determine
EEG patterns
commonest at
each level of
anaesthesia?
EEG analysed
from 2000
healthy adults
undergoing
different levels
of anaesthesia

Step 1
Step 2
Step 3
Q: How does BIS analyse EEG?
How the algorithm was
determined
Q: How does BIS analyse EEG?
EEG patterns
compared with
algorithm
Score
determined
from 0 100
Anaesthesia
recommended
40-60
Patients EEG
analysed
How the real time analysis
works on patients

Burst suppression
Power spectral analysis
Bispectral:
Phase coupling
Q: How does BIS analyse EEG?
Bispectral:
Degree of EEG synchronisation
Q: How does BIS analyse EEG?
Q: How does BIS analyse EEG?
Q: How does BIS analyse EEG?