black box nyc.ppt - case western reserve universitycase.edu/med/bioinformatics/black...

Stephan A Mayer, MDStephan A Mayer, MDAssociate Professor of Clinical Neurology andAssociate Professor of Clinical Neurology and

Neurological SurgeryNeurological SurgeryDirector, Director, Neuro-ICUNeuro-ICU

Columbia-Presbyterian Medical CenterColumbia-Presbyterian Medical Center

INSIDE THE BLACK BOX

Monitoring in the ICU

• What we have been• Where we are now

Three Phases of the History ofNeuromonitoring

• Phase 1: Clinical neuromonitoring• 1960-1980• React to clinical events


• CV: ECG, MAP, CVP, PAD, CO, troponin• Pulmonary: O2 sat, ABGs, CXR• ID: Temperature• Renal: I/O s, creatinine, electrolytes• Endocrine: Glucose• Heme: CBC, coags

• Neuro: Exam!

Intracranial Mass Effect

Sternal Rub



• Phase 2: Physiological neuromonitoring• 1980-2000• React to pathophysiological events

Parenchymal

Micosensor

Richmond Bolt

Epidural Monitor

Ventricular

catheter

ICP

CPP

MANNITOL40g 20g 20g


• What we have been• Where we are now• Where we need to go

ICP: Dead End Box

Neuro-ICU Brain Monitoring• ICP

• cEEG

• CBF

• SJVO2

• TCD• Brain Tissue O2

• Microdialysis

COURTESY DR PAUL VESPA

Integrated NICU Monitoring

System of the Future

cEEG

ICP/CPP

Brain Tissue Oxygenation

JVO2 sat/AVDO2

Intracerebral Microdialysis

TCD/CBF

BP

CI

ETCO2

pO2

Sedation

Temp

Chaos

and

Confusion

COURTESY DR MICHAEL DEGEORGIA

Integrated NICU Multimodality


IntegratedNICU

Monitoring

System

NICU Records

cEEG

ICP/CPP


JVO2 sat/AVDO2


TCD/CBF

BP

CI

ETCO2

pO2

Sedation

Temp

Post Hoc

“Data Mining”

Real Time

Physiologic

Interrelationships

ADAPTED COURTESY OF DR MICHAEL DEGEORGIA

Physiologic Brain Health Physiologic Drivers

Event

Monitoring

PLUG AND PLAY

CONNECTIVITY

USER INTERFACE

The two essential components

of an effective MMM system

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ICP liICP reptiO2 reptiO2 liTemp re

Temp liCPP TrendMAP Trend

Thiopental

Glycerol

Mannitol

Hetastarch

THAM

Body positioningHetastarch

anisocoria: l>r

Multimodal monitoring during hypothermia

COURTESY DR THORSTEN STEINER



• Phase 2: Physiological neuromonitoring• 1980-2000• React to pathophysiological events

• Phase 3: Neurophysiological decision support• 21st Century• Understand and manage complex physiology

to prevent pathophysiological events



IntegratedNICU

Monitoring

System

NICU Records

cEEG

ICP/CPP


JVO2 sat/AVDO2


TCD/CBF

BP

CI

ETCO2

FiO2

Sedation

Temp

Post Hoc

“Data Mining”

Real Time

Physiologic

Interrelationships



Event

Monitoring

Brain Oxygen Tension Monitoring:LICOX

• Assesses adequacyof cerebralperfusion

• Early warning ofdifferences betweenbrain tissue oxygensupply and demand

• Independent,sensitive outcomeprediction

Good Outcome Poor Outcome

23%

65% 35%

77% P=0.05

Kett-White R et al. Neurosurgery.2001;50; 1213-21

Effect of Brain Tissue Hypoxia on OutcomeSubarachnoid Hemorrhage

DURATION

OF CRITICAL

HYPOXIA:

<10 MM HG

PbrO2mm Hg

ICPmm Hg

CPPmm Hg

Scatterplot of Cerebral Perfusion Pressure by Brain Oxyge

Time Period 900-1000 Minutes

r2 = 0.6934

30 40 50 60 70 80 90

CPP

20

22

24

26

28

30

32

34

36

pbO

2

CONNECTIVITY

USER INTERFACE

The two essential components

of an effective MMM system

Cerebral Autoregulation81

Ce

reb

ral

Blo

od

Flo

w

Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214-227.

100 200

normotensive

chronic hypertensive

50 150 250

VASOPARALYSIS

MAP (mm Hg)

Scatterplot of Cerebral Perfusion Pressure by Brain Oxyge

Time Period 900-1000 Minutes

r2 = 0.6934

30 40 50 60 70 80 90

CPP

20

22

24

26

28

30

32

34

36

pbO

2



IntegratedNICU

Monitoring

System

NICU Records

cEEG

ICP/CPP


JVO2 sat/AVDO2


TCD/CBF

BP

CI

ETCO2

ETCO2

Sedation

Temp

Post Hoc

“Data Mining”

Real Time

Physiologic

Interrelationships



Event

Monitoring

Po

“DatReal Time

Physiologic

Interrelationships

Things I Hate About My GE Bedside Monitor

• I can t analyze time trend data easilyat the bedside

• I can only look at data over time• I can t adjust the Y axis scale• I can only view data on the X axis

over 24 hours, no longer• I can only look at 3 variables at a

time• I can t see therapeutic interventions

JOSEPH HERMAN

435-67-89

Heart rateRespirationsSBPDBPMAPTemp-FoleyTemp-BrainSerum GlucoseSerum OsmolalityICPCPP

FiO2Minute VentilationPeak Airway PressVO2ETCO2

PhenylephrineDobutaminePropofolFentanylMannitol (Bolus)Phenytoin (Bolus)

PbrO2CBF(ml/100g/min)EEG Alpha/DeltaEEG Total PowerMD-GlucoseMD-GlutamateMD-LactateMD-PyruvateMD-Glutamate

TIMETRENDS

TEMPANALYSIS

CPP-PBrO2OPTIMIZATION

SCATTERPLOTS

SEIZUREDETECTION

HR

Temp-Foley

MAP

RR

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

HR

Temp-Foley

MAP

RR

ETCO2

JOSEPH HERMAN

435-67-89

Heart rateRespirationsSBPDBPMAPTemp-FoleyTemp-BrainSerum GlucoseSerum Serum OsmolalityOsmolalityICPCPP




TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

HR

Temp-Foley

MAP

RR

ETCO2

MAN

NITO

L

MAN

NITO

L

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

HR

Temp-Foley

MAP

RR

Phenyl-ephrine

MAN

NITO

L

MAN

NITO

L

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

HR

Temp-Foley

MAP

RR

EEG-ADR

MAN

NITO

L

MAN

NITO

L

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

TIME SAMPLED: 2 DAYS AGO (JAN 24 8:00 – JAN 25 8:00)

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

TIME SAMPLED: YESTERDAY (JAN 25 8:00 – JAN 26 8:00)

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

R2: ICP•PBrO2

R2: MAP•PBrO2

ICP

PbrO2

Target CPP

95-105 mm Hg

SLIDE COURTESY DR J MICHAEL SCHMIDT

JOSEPH HERMAN

435-67-89





TIMETRENDS

TEMPANALYSIS


SCATTERPLOTS

SEIZUREDETECTION

NCSE

midaz

What the clinician wants from ICU

information platforms

• Connectivity: Boxes that talk to eachother

• Real time data on rounds at thebedside

• Open data architecture that allowsinnovation

• Logical clean graphical user interfacedeveloped by clinicians

black box nyc.ppt - case western reserve universitycase.edu/med/bioinformatics/black...

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