31 de março de 2011

Monitoring the monitors—beyond risk management

British Journal of Anaesthesia 97 (1): 1–3 (2006) / doi:10.1093/bja/ael139

Monitoring, to health care professionals and in particular anaesthetists, usually means the continuous measurement of patient variables over time. However, the word monitor derives from the Latin monere (to warn) and modern English dictionaries include almost a dozen different connotations. These range from an observational warning or recording device (or individual) to audiovisual terminology, a senior school pupil and types of lizard or warship. In a similar way, the term monitor in anaesthesia, critical care, pain management or perioperative medicine actually encompasses a variety of technologies that address diverse but overlapping aspects of anaesthesia and medical care. Over the past two decades, these technologies have advanced greatly and the availability of monitoring devices has multiplied exponentially. This has occurred in conjunction with the developments in electronics, computing, information technology and mobile communications, which has characterized the past 20 yr. This issue of the British Journal of Anaesthesia is based on the symposium held in March 2006 and organized jointly by The Royal College of Anaesthetists and British Journal of Anaesthesia. The articles range from the interaction between humans and machines, new and emerging technologies and their application not only inside and outside the operating room but also at the extremes of environments where medical care may be needed.

In order to fully understand the panoply of modern monitoring, we should remember the progress made in the very recent past. When exactly instrumental monitoring started in anaesthetic practice is unclear, but the core guiding principle of the profession of anaesthesia has always been ‘For some must watch, while some must sleep’ (Hamlet, W. Shakespeare). ‘Vigilance’ has been the motto of the ASA since it was founded in 1905. While some of us can still remember the days up to the mid-1980s when this vigilance, in practical terms, was restricted to an anaesthetist’s utilization of senses by inspection or palpation for clinical signs (observation of the patient’s colour with a finger on the pulse), there has been convincing evidence that our human senses by themselves, are not reliable in keeping ‘eternal vigilance’. As early as 1947, it was shown that observation could not detect cyanosis reliably. In the 1980s, studies proved the inadequacy of reliably detecting hypoxia or adequacy of ventilation by clinical means alone, and it became clear that more sophisticated aids were required. Advances in technology made it possible to introduce pulse oximetry and capnography into clinical practice and it was immediately evident that these monitors would supplement the deficiencies in our clinical abilities. These devices were incorporated into the recommendations for standards of monitoring by ASA and the Association of Anaesthetists of Great Britain and Ireland. Studies in the 1990s convincingly proved that the use of pulse oximetry and capnography were crucial in the prevention and early detection of many unwanted events, and that they significantly reduced the number of critical incidents. For this reason, in the UK by the mid-1990s, the recommended monitoring standards came to be considered mandatory for safety and risk management, and lack of these during anaesthesia had become indefensible in cases of medical litigation. However, it must be remembered that in some parts of the world these standards may still be considered an unaffordable ‘luxury’. [...]

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