Monitoring, past, present, future. A personal journey.

A little over 40 years ago, anesthesiology in the United States became recognized as a specialty. At that time, its practice was largely that of an art, the science of which was yet to come. A finger on the pulse, observation of color, skin turgor, perspiration, and perhaps a blood pressure cuff in adults, and an estimation of the reflex signs of anesthesia were the standards for the assessment of the patient status and 'the depth of anesthesia'. How far have we come in the intervening years? The journey, as reflected in the experience of one physician, will be held up to the looking-glass; easily as astounding as that through which Alice passed. Caught as we are in the socio-economic climate of the present, how shall we react? Has the gadgetry and electronics of this day given us a meaningful cost-effective handle on a decreased morbidity and mortality? What impact is there on decision-making and outcome? What indeed is the contribution of the machine versus the newer agents, techniques, and the advanced educational milieu. The first attempts at monitoring were clearly directed toward the cardiovascular system. The devices developed were simple and non-invasive. The Riva-rocci method of measuring blood pressure was first applied in anesthesia by Harvey Cushing at the turn of the century. But it was 40 years before the electrocardiogram was introduced as an instrument of potential importance. It took another 25 years for it to have general acceptance, and even later for the anesthesiologist to become comfortable with it as a diagnostic tool.(ABSTRACT TRUNCATED AT 250 WORDS)

The computer-based anesthetic monitors: the Duke Automatic Monitoring Equipment (DAME) system and the microDAME.

From 1972 to 1983 the Duke University Department of Anesthesiology designed, built, and maintained most of its own operating room patient monitoring equipment. Construction of a new hospital facility in 1980 provided the opportunity to design and test a new computer-based system, the Duke Automatic Monitoring Equipment (DAME) System. The system consist of microcomputer-based instrumentation on monitoring carts, which communicate with a central minicomputer that allows selection of different software monitoring packages based on the needs of the patient. Multiple problems, including frequent total monitoring failures during surgery, plagued the DAME System in its first year of operation. Despite resolution of many of these problems, user acceptance was poor because of the large size and weight of the monitoring carts, the inadequate quality of displayed physiological waveforms, and inability to overcome the difficulties of the man-machine interface. Because the remaining problems could not be rectified with the existing monitoring carts, a new generation of monitors was designed. The smaller, multiprocessor microDAME was designed to be as automatic and user tolerant as possible. It would omit much of the flexibility that had proved undesirable in the DAME system. When the microDAME was nearly completed, however, departmental research in that area ceased. It remains for others to apply our experiences to further improve operating room patient monitors.

The EEMG--a practical index of cortical activity and muscular relaxation.

In a continuing study of the EEG as a monitor of cortical activity during anesthesia using a time-domain wave analyzer, the contamination of the EEG by scalp muscle activity was observed. A measure of this EMG activity was extracted from the combined EEG/EMG wave obtained from two electrodes placed over the left frontalis muscle and right mastoid process. Clinical work with this variable showed that the EMG can serve both as a reliable guide to patient muscular relaxation and an indicator of unacceptable muscle contamination of the EEG. This extracted variable in conjunction with the analyzed EEG has served as a valid indicator in the assessment of the anesthetic state. The system has been successfully employed in the management of nearly 1000 surgical patients.