QRS Diagnostics (Plymouth, MN) ECG monitoring system allows a 12-lead ECG to be collected via a serial port on an IBM-compatible laptop computer (Fig. 1). Oxygen saturation was monitored via a QRS Medical SpirOxCard. The plug-in card enables the laptop to emulate a standard pulse oximeter.
Heart and breath sounds were evaluated with an electronic stethoscope model 718-7120 supplied by Cardionics Inc (Webster, TX). It is an amplified stethoscope that has a line-level output for transmission of breath and heart sounds. The audio from the stethoscope was routed into the laptop computer via the microphone input transmitted as part of the audio-video stream. Automated noninvasive arterial blood pressure readings were made with an automated off-the-shelf BP cuff (DynaPulse 3000AUTO; Pulse Metric, Inc., San Diego, CA) connected to the RDTU by RS232 output.
ETco2 readings were made using a Datex-Ohmeda (Louisville, CO) hand-held ETco2 monitor connected by serial output to the RDTU, once the endotracheal tube was secured. The ETco2 data were sent as digital values, making the best use of the available bandwidth, and could be displayed as values, or reconstructed into a waveform.
Streaming room video was possible by a standard fixed video-conferencing camera (Pixera PXG-160N-STl; Pixera Corporation, Los Gatos, CA) and any standard hand-held camcorder, manipulated by the system technician. The video and audio were sent using Microsoft's Net Meeting software (Redmond, WA), which also supported chatbox text messages. By means of a video switch in the RDTU, the video feed could be changed to a multitude of video inputs; including the TrachView (Englewood, CO) fiberoptic endotracheal intubation system. Video from the various cameras was transmitted to Richmond, Virginia, for viewing by the consulting anesthesiologist.
Transmission of the streaming audio/text, video, and real-time vital signs was via InMarSat B satellite phone. The InMarSat phone provides a 64-Kbps (kilobits per second) data rate to an Internet Service Provider in the U.S. The physiologic data were encrypted, collected and archived using software developed by Televital, Inc. (Milpitas, CA). The information was then available via secure, password-protected Internet connection to the laboratory in Richmond. Viewing and interpretation can be readily available via any computer with a secure Internet connection. Figure 2 illustrates the screen and information available to observers on both ends of the connection. Figure 3 and Figure 4 illustrate how the data were recorded by the distant consultant.
Seven cases were successfully completed and transmitted using the protocol described during two surgical missions to Ecuador in 2002 (Table 2). In June of 2002, four cases were transmitted, consisting of two general anesthesia and two spinal anesthesia. Three general anesthesia cases were added in December. Operations consisted of cholecystectomies, herniorrhaphies, and lipoma resections.
After establishment of satellite connection, the RDTU was set up for transmission of patient data. Patients were examined locally for preoperative anesthetic planning, and all cases were discussed with the distant consultant. The anesthetic plans were agreed upon, based on the resources available in the mobile unit. This was accomplished with video and verbal communications over the satellite connection, with no loss of transmission. This communication was continued throughout the case to discuss any changes to the anesthesia or the status of the patient. When necessary, Spanish to English translation was provided by one of the authors (SC).
Anesthesiologists on both ends were fully trained anesthesia attending physicians. Although none needed consultation, they agreed to participate in this validation study as a test of technology, recognizing its value as a means of documentation, consultation, and education.
Upon establishment of an anesthetic plan, vital signs transmission was begun at rates displayed in Table 3. Patient monitoring was continuous throughout administration of oxygen, surgery, and to tracheal extubation. Airway view through the TrachView fiberoptic intubation system (Fig. 5) was available for all general anesthesia, with confirmation of endotracheal tube intubation verbally acknowledged by the distant consultant and recorded on the anesthetic record (Fig. 3). Placement was also confirmed by audio transmission of breath sounds and verbally acknowledged by the distant consultant. ECG, heart rate, and pulse oximetry were available for all seven surgeries. The June cases depended upon manual arterial blood pressure monitoring with verbal communication of results. December cases had the additional capabilities of electronic arterial blood pressure and end-tidal CO2 monitoring and transmission for all three cases (Table 4).
Although the application and utility of telemedicine has been widely reported in the literature, an extensive review suggests that this report may be the first full exploration of teleanesthesia, defined as telementoring and telemonitoring of preoperative planning, postoperative care, and real-time vital signs monitoring during anesthesia for a surgical procedure. Monitoring of vital signs while in audio and visual contact during anesthesia in a remote location capitalizes on previous work by others addressing the issue of remote vital signs monitoring (11–16,26,27) and adds a new level of collaboration not previously applied to address patient safety.
As more operations are performed in remote locations, for disaster situations or even in space travel, safety measures for anesthesia are strongly needed. Telementoring and telemonitoring by means of mobile monitoring platforms and distance consultations provide methods to deliver a safer anesthesia with virtual collaboration. Shared responsibility, shared expertise, and a common data set of patient variables could lead to reduced morbidity and mortality.
In the study presented here, technologies were combined for use in the RDTU. American Society of Anesthesiologists monitoring guidelines are for the routine use of ECG, pulse oximetry, noninvasive arterial blood pressure, and ETco 2. All of these monitors were available through the RDTU with output from these monitors presented locally and distantly on identical computer screens through a satellite connection. Auditory and visual monitoring through the RDTU provided additional monitoring capabilities. Although interruptions do occur in such remote settings, they have been minimal in quantity, duration (<1 min), and effect on monitoring. Future avenues for such work should include synchronization provisions to provide data collected during interruptions in connectivity. Figures 2 and 3 show the data available for telemonitoring. Figure 3 specifically shows a relatively standard anesthetic record documented using this system to monitor from a distance.
As we explore remote regions of the earth and the universe for longer periods of time and at greater distances, we must expect the need for lifesaving surgical procedures without the availability of standard personnel. Robotic surgical tools are being adapted for expeditions further afield where a skilled surgeon may not be available. Likewise, skilled anesthesiologists may not be physically present in all situations requiring their unique skills. Developing systems as presented here to travel wherever there is need, or wherever humans venture, should encourage exploration and possibly provide better patient outcomes for those who reside in remote places. In addition, the concept could be extremely helpful in disaster situations, with the simple requirements of qualified personnel and satellite (or other, low bandwidth) connectivity.
The authors would like to acknowledge the Cinterandes Foundation of Ecuador for helping to make this work possible by providing the facilities and the surgical cases. We thank Anita Vicuña, MD, of the Cinterandes Foundation and Patricio Escandon, MD, of Yale University for assistance as on-site anesthesiologists during the course of this work. We wish to thank Ms. Chasity Roberts for her editorial help. For help with the software, the authors specifically thank Yair Lurie, MS, and Kishore Kumar, PhD, of Televital, Inc. Their work was instrumental in allowing streaming and archiving of patient physiologic data.
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© 2006 International Anethesia Research Society
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