Prediction of Cardiorespiratory Compromise on Hospital ... · 04/10/2018  · •All lines will be...

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Prediction of Cardiorespiratory Compromise on Hospital General Care Units – Are We There Yet? Ashish Khanna, MD, FCCP, FCCM The Cleveland Clinic Lerner College of Medicine October 4, 2018 12:00 pm – 1:00 pm PDT

Transcript of Prediction of Cardiorespiratory Compromise on Hospital ... · 04/10/2018  · •All lines will be...

  • Prediction of Cardiorespiratory Compromise on Hospital General Care

    Units – Are We There Yet?

    Ashish Khanna, MD, FCCP, FCCMThe Cleveland Clinic Lerner College of Medicine

    October 4, 201812:00 pm – 1:00 pm PDT

  • Moderator

    2

    Claire MannehDirector of ProgramsCHPSO, a Division of the Hospital Quality Institute

  • Housekeeping Items• All lines will be muted. Raise your hand if you wish

    to be unmuted.

    • A copy of the slides and recording will be available within 1-3 business days

    • 1 CE unit will be provided to CHPSO/CHA member hospitals who attend the entire session (12:00 pm -1:00 pm)• Complete the survey by October 11, 2018• CE certs will be emailed within 3-5 business days 3

  • How to ask a question

    4

  • Today’s Speaker

    5

    Ashish Khanna, MD, FCCP, FCCMCleveland Clinic Lerner College of Medicine – Staff Intensivist with the Center for

    Critical Care– Assistant Professor of Anesthesiology

  • Prediction of Cardiorespiratory Compromise on Hospital General Care Units – Are We There Yet?

    Ashish K. Khanna MD, FCCP, FCCMStaff Intensivist, Surgical ICU & Center for Critical Care

    Staff Anesthesiologist, Department of General AnesthesiologyVice-chief for Research, Center for Critical Care

    Assistant Professor of Anesthesiology CCLCM, Anesthesiology Institute & Department of Outcomes Research

    Cleveland Clinic Foundation, Cleveland, OH,USA

    @KhannaAshishCCF

  • Disclosures

    •Medtronic•La Jolla Pharmaceuticals

  • Objectives

    Understand the challenges of predicting cardiorespiratory compromise, and how to address them1

    Learn potential benefits of continuous monitoring on the general care floor to improve outcomes2

    Identify who to monitor as well as what and how to monitor3

    Translate expanded knowledge of cardiorespiratory compromise into improvements in practice and patient monitoring protocols – integrate better in-patient monitoring on the general care floors

    4

  • The Scope of the Problem

    Cardiorespiratory complications are the most common cause of 30-day postoperative mortality[4]

    Unplanned ICU admissions may have respiratoryindication in 17-47% of cases particularly postoperative pulmonary complications[5-8]

    AHRQ rated postoperative respiratory failure as the fourth most common patient safety event[4]

    Hypotension and hypoxemia on the general care floor (GCF) is common, profound, prolonged and cannot be reliably predicted [1,2]

    49% of cardiac arrest on GCF had a respiratory cause – higher than ICU[3]

  • AHRQ Quality Indicators - 2015

    Indicator Description Numerator Denominator Observed Rate per 1000

    PSI #2 Death Rate on Low-Mortality DRG’s 1,822 5,636,509 0.32

    PSI #4

    PSI #11

    PSI # 13

    Death Rate among Surgical Inpatients with Serious Treatable Conditions

    A: DVTB: PneumoniaC: SepsisD: Cardiac Arrest; shockE: GI Bleed

    Postoperative Respiratory Failure

    Postoperative Sepsis

    22,014

    1,2586,1515,6227,7061,277

    22,402

    4,822

    185,587

    2,228,418

    501,689

    118.62

    10.05

    9.61

  • 0.3- 17% Naloxone hypoventilation hypercarbia SpO2

  • Anesth Analg 2015 Sep;121(3):709-15.[9]

  • Desaturation on Surgical WardsMinutes hypoxemia per hour

    Blinded ward monitoring

    ≈850 non-cardiac surgical patients [9]

  • Hypoxemia episodes of varying duration

    90% of episodes during which saturation was

  • Hypoxemia is common!

    SpO2 Duration % of total 10min/hr. 21%20min/hr. 8%5min/hr. 8%

  • Can we predict post operative hypoxemia?

  • Post-operative Hypoxemia Common Culprits…

  • Common Culprits…

    • Hypoventilation• Residual narcotics• Residual benzos• Residual inhaled anesthetics• Residual muscle relaxants

    • Sleep Disordered Breathing/Obstructive Sleep Apnea

    • V/Q mismatch and Shunt

    • Atelectasis• Pulmonary edema

    • Surgery –Type/Duration ----Pain, splinting, abdominal wall binding, abdominal distension

    • Age• Habitus • Type and Duration

    of Anesthesia

  • E.g. surgery type/duration, type and duration of anesthesia, residual narcotics

    E.g. Obesity, comorbidities, advanced-age, sleep disordered breathing/

    obstructive sleep apnea

    E.g. frequency of vital signs checkups

    Risk Factors for Cardiorespiratory Compromise

    Patient Factors

    Treatment Factors

    Area of Care Factors

    PERFECTSTORM

    Saunders R, Ajizian S, Mestek M. Chapter 11: Respiratory Compromise in Moderate and Deep Sedation. Moderate and Deep Sedation in Clinical Practice, Second Edition, ed. Richard D. Urman and Alan D. Kaye. Published by Cambridge University Press. © Cambridge University Press 2017.

    [10]

  • [2]

  • Incidence Of Patients With An Average Number Of Minutes Per Hour Of Hypoxemia > X During Monitoring

    A. SpO2

  • • Sensitivity Analysis• Time–Weighted SpO2

    [2]

  • Anesth Analg. 2016 Dec;123(6):1471-1479

    [11]

  • • At 95% threshold, at least 10 min/hour of hypoxemia in 79% of patients• At 90% threshold, at least 10 min/hour of hypoxemia in 19% of patients• At 85% threshold, at least 10 min/hour of hypoxemia in 1% of patients

    [11]

  • Can we predict post operative hypoxemia?

  • If We Cannot Predict It, Can We Monitor It?

    •Better monitoring?•Who to monitor?•What to monitor?•How to monitor?

  • Anesthesiology 2015;122:659-65

    [12]

  • Opioid Induced Respiratory Depression

    • 77% death/severe brain damage

    • 88% within 24 hr. post-surgery

    • 9% STOP-BANG

    • Multiple prescribers• Non-opioid sedatives• Inadequate nursing

    response

    97% preventable – better monitoring and response

    42% - 2hr of last check

    [12]

  • Association of Opioids and Sedatives with Increased Risk of In-Hospital Cardiopulmonary Arrest.

    Overdyk FJ, Dowling O, Marino J, et. al.PLOS ONE 11.2 (2016): e0150214.

    Opioids/Sedative Use2007-1012

    Cardiac Arrest(n=96,554)

    No Cardiac Arrest(n=12,180,137)

    Odds Ratio* 95% CI

    Both Opioid and Sedative 41.0 % 21.8% 3.47 (3.40, 3.54)

    Opioid only 28.0% 31.4% 1.81 (1.77, 1.85)

    Sedative only 13.8% 14.3% 1.82 (1.78, 1.87)

    Neither Opioid Nor Sedative 17.2% 32.6% Ref.

    “Low Acuity” Patients Cardiac Arrest

    General Care Floor 21,564

  • Manually recorded data were, on an average 6.5% higher than those recorded via automated systems!

    Anesth Analg 2014;118;326-31

    [13]

  • If we cannot predict it, can we monitor it ??

    • Better monitoring? YES• Who to monitor? EVERYONE • What to monitor?• How to monitor? CONTINUOUS (AUTOMATED)

  • [13]

  • Pulse Oximetry…• 22,992 participants • No decrease in-hospital mortality• No decrease in-hospital stay• No decrease in transfer to ICU• No decrease in overall mortality

    • Potential increased vigilance and decreased pulmonary complications

  • Can Continuous Monitoring Help?

    CPOX – significant improvement in detection

    on floorTrend towards less

    ICU transfers

    Rescue team & Mortality –inconclusive

    Capnography –early warning

    before desaturation

    ( O2 supplementation)

    Anesthesiology 2017;125:2019-2029

  • Anesthesiology. 2012;116(2):248-273

  • Some answers…

    • Multimodal analgesia• Improved monitoring and feedback• Continuous capnography • Continuous pulse oximetry • Identify risk factors• Education • Continuous supplemental oxygen

  • Future Directions??

    etCO2 RR SpO2 HR ? Blood Pressure

  • Improved and smarter monitoring for everyone?

    WHAT TO MONITOR? CARDIORESPIRATORY

    Available evidence has shown that cardiorespiratory

    compromise is common, goes undetected and is largely

    unpredictable

    HOW TO MONITOR? CONTINUOUS (AUTOMATED)

    Continuous monitoring of all patients on the regular floor appears to be the answer to detecting cardiorespiratory

    compromise early

    WHO TO MONITOR? EVERYONE

    APSF recommends continuous monitoring for

    all patients receiving opioid therapy in the postoperative

    period, especially when supplementary oxygen is

    administered

    BETTER MONITORING? YES

    Continuous monitoring of capnography and oximetry can provide clinicians with

    early identification of evolving Respiratory

    Compromise, allowing for early intervention that may

    prevent tragic consequences

    [1,2,14,15]

  • The RNF – Real time monitoring!

  • Trending respiratory vital signs [16]

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    2/3/06 18:43 2/3/06 18:57 2/3/06 19:12 2/3/06 19:26 2/3/06 19:40 2/3/06 19:55 2/3/06 20:09

    HR beats/min

    SaO2 %

    "Code Blue"

    RR breaths/min

    ETCO2 mmHg

    Continuous capnography/oximetry monitoring during PCA

    Chart2

    38751.781493055638751.781493055638751.781493055638751.781493055638751.7814930556

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    38751.784270833338751.784270833338751.784270833338751.784270833338751.7842708333

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    38751.785659722238751.785659722238751.785659722238751.785659722238751.7856597222

    38751.786354166738751.786354166738751.786354166738751.786354166738751.7863541667

    38751.787048611138751.787048611138751.787048611138751.787048611138751.7870486111

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    38751.788437538751.788437538751.788437538751.788437538751.7884375

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    38751.790520833338751.790520833338751.790520833338751.790520833338751.7905208333

    38751.791215277838751.791215277838751.791215277838751.791215277838751.7912152778

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    38751.792604166738751.792604166738751.792604166738751.792604166738751.7926041667

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    38751.799548611138751.799548611138751.799548611138751.799548611138751.7995486111

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    38751.812048611138751.812048611138751.812048611138751.812048611138751.8120486111

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    HR beats/min

    SaO2 %

    "Code Blue"

    RR breaths/min

    ETCO2 mmHg

    79

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    22

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    100

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    103

    86

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    102

    87

    50

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    116

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    89

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    22

    112

    84

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    18

    115

    83

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    16

    120

    85

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    84

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    87

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    124

    85

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    17

    123

    83

    37

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    122

    83

    30

    22

    119

    82

    32

    19

    132

    80

    123

    25

    17

    132

    80

    113

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    80

    103

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    80

    93

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    83

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    80

    73

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    80

    63

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    80

    53

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    80

    43

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    80

    33

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    80

    23

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    17

    129

    77

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    20

    133

    75

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    Data a.

    PcuDateTimeSaO2 %HR beats/minPCA BolusETCO2 mmHgRR breaths/minCp (MSO4) mcg/cc1/31/06 23:59ModuleAlarmStatusBPM Lower LimitSpO2 Lower LimitMSO4

    2/1/06 0:00958840221.629121/31/06 23:598900.1086115

    2/1/06 0:01968737211.619102/1/06 0:008900.10794

    2/1/06 0:02968239191.609142/1/06 0:018900.10728

    2/1/06 0:03968140191.599252/1/06 0:028900.10662

    2/1/06 0:049582391.589412/1/06 0:038900.10596

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    2/1/06 4:38947747173.348762/1/06 4:248900.22325

    2/1/06 4:39947749143.308812/1/06 4:258900.22059

    2/1/06 4:40937748153.270032/1/06 4:268900.21800

    2/1/06 4:41937846163.238592/1/06 4:278900.21591

    2/1/06 4:42987943153.201852/1/06 4:288900.21346

    2/1/06 4:43977644143.166162/1/06 4:298900.21108

    2/1/06 4:44977647133.131462/1/06 4:308900.20876

    2/1/06 4:45957648163.097712/1/06 4:318900.20651

    2/1/06 4:46947748133.064882/1/06 4:328900.20433

    2/1/06 4:47937647143.038182/1/06 4:338900.20255

    2/1/06 4:48947750123.006912/1/06 4:348900.20046

    2/1/06 4:49957548102.976452/1/06 4:358900.19843

    2/1/06 4:50957648112.946752/1/06 4:368900.19645

    2/1/06 4:51937547132.917792/1/06 4:378900.19452

    2/1/06 4:52957648112.889532/1/06 4:388900.19264

    2/1/06 4:53947650142.866502/1/06 4:398900.19110

    2/1/06 4:54957649132.839462/1/06 4:408900.18930

    2/1/06 4:55947548112.813042/1/06 4:418900.18754

    2/1/06 4:5696774892.787222/1/06 4:428900.18581

    2/1/06 4:57967747102.761972/1/06 4:438900.18413

    2/1/06 4:58947748112.737272/1/06 4:448900.18248

    data b.

    PcuDateTimeHR beats/minSaO2 %"Code Blue"RR breaths/minETCO2 mmHgPulseAverageBPM Lower LimitSpO2 Lower LimitAlarm EtCO2/BPM48265050

    2/3/06 18:4579942829

    2/3/06 18:4777932730890

    2/3/06 18:4876952730890

    2/3/06 18:4975922631890

    2/3/06 18:5078952431890

    2/3/06 18:5183932428890

    2/3/06 18:5279942628890

    2/3/06 18:5380942527890

    2/3/06 18:5482942828890

    2/3/06 18:5581962730890

    2/3/06 18:5679942728890

    2/3/06 18:5783932627890

    2/3/06 18:5883942729890

    2/3/06 18:5984922728890

    2/3/06 19:0082942627890

    2/3/06 19:0185912829890

    2/3/06 19:0287902827890

    2/3/06 19:0383902530890

    2/3/06 19:0486922828890

    2/3/06 19:0584932730890

    2/3/06 19:0685942724890

    2/3/06 19:0785932624890

    2/3/06 19:0883902626890

    2/3/06 19:0982912523890

    2/3/06 19:1082922726890

    2/3/06 19:1181942725890

    2/3/06 19:1285922627890

    2/3/06 19:1386932927890

    2/3/06 19:1481942728890

    2/3/06 19:1575913027890

    2/3/06 19:1684932929890

    2/3/06 19:1789932827890

    2/3/06 19:1992932928890

    2/3/06 19:1989913226890

    2/3/06 19:2086903226890

    2/3/06 19:2190933425890

    2/3/06 19:2292923425890

    2/3/06 19:2392933524890

    2/3/06 19:2490933826890

    2/3/06 19:2594943929890

    2/3/06 19:2691943924890

    2/3/06 19:2794923826890

    2/3/06 19:2893933823890

    2/3/06 19:2993903721890

    2/3/06 19:3096933524890

    2/3/06 19:3189943824890

    2/3/06 19:3297934622890

    2/3/06 19:3398904624890

    2/3/06 19:3499924223890

    2/3/06 19:35101943524890

    2/3/06 19:3698913826890

    2/3/06 19:3793893622890

    2/3/06 19:3897893621890

    2/3/06 19:3986904221890

    2/3/06 19:4099894422890

    2/3/06 19:41102884122890

    2/3/06 19:42103894221890

    2/3/06 19:43105923722890

    2/3/06 19:44109913722890

    2/3/06 19:45100904222890

    2/3/06 19:46103864521890

    2/3/06 19:47102875022890

    2/3/06 19:48116854819890

    2/3/06 19:49114894422890

    2/3/06 19:50112844518890

    2/3/06 19:51115834716890

    2/3/06 19:52120854818890

    2/3/06 19:53119844319890

    2/3/06 19:54117873921890

    2/3/06 19:55119864319890

    2/3/06 19:56121884518890

    2/3/06 19:57124854017890

    2/3/06 19:58123833721890

    2/3/06 19:59122833022890

    2/3/06 19:59119823219890

    2/3/06 20:00132801232517890

    2/3/06 20:00132801132517890

    2/3/06 20:00132801032517890

    2/3/06 20:0013280932517890

    2/3/06 20:0013280832517890

    2/3/06 20:0013280732517890

    2/3/06 20:0013280632517890

    2/3/06 20:0013280532517890

    2/3/06 20:0013280432517890

    2/3/06 20:0013280332517890

    2/3/06 20:0013280232517890

    2/3/06 20:01129772420130890

    2/3/06 20:02133752119129890

    2/3/06 20:03133702320130890

    2/3/06 20:04136742418128890

    2/3/06 20:05132782524125890

    2/3/06 20:06129722621129890

    2/3/06 20:077125129890

    2/3/06 20:07890

    2/3/06 20:07890

    2/3/06 20:07890

    2/3/06 20:08129890

    2/3/06 20:09890

    2/3/06 20:097929129890

    2/3/06 20:09890

    2/3/06 20:108235132890

    2/3/06 20:1022890

    2/3/06 20:1121890

    2/3/06 20:1121890

    2/3/06 20:118131133890

    2/3/06 20:11890

    2/3/06 20:1121890

    2/3/06 20:1119890

    2/3/06 20:12890

    2/3/06 20:12890

    2/3/06 20:128029134890

    2/3/06 20:1221890

    2/3/06 20:12890

    2/3/06 20:12890

    2/3/06 20:12890

    2/3/06 20:13802922129890

    2/3/06 20:14812422127890

    2/3/06 20:15832622128890

    2/3/06 20:16812622125890

    2/3/06 20:17890

    2/3/06 20:17890

    2/3/06 20:17822621128890

    2/3/06 20:17890

    2/3/06 20:17890

    2/3/06 20:17890

    2/3/06 20:17890

    2/3/06 20:18802721127890

    2/3/06 20:18890

    2/3/06 20:18890

    2/3/06 20:18890

    2/3/06 20:18890

    2/3/06 20:19890

    2/3/06 20:19890

    Figure 5a.

    Fig 5. Monitor Trend data: a. Opioid induced respiratory depression b. Aspiration peumonia

    Figure 5a.

    38749.000046296338749.000046296338749.000046296338749.000046296338749.0000462963

    38749.000740740738749.000740740738749.000740740738749.000740740738749.0007407407

    38749.001435185238749.001435185238749.001435185238749.001435185238749.0014351852

    38749.002129629638749.002129629638749.002129629638749.002129629638749.0021296296

    38749.002824074138749.002824074138749.002824074138749.002824074138749.0028240741

    38749.003518518538749.003518518538749.003518518538749.003518518538749.0035185185

    38749.00421296338749.00421296338749.00421296338749.00421296338749.004212963

    38749.004907407438749.004907407438749.004907407438749.004907407438749.0049074074

    38749.005601851938749.005601851938749.005601851938749.005601851938749.0056018519

    38749.006296296338749.006296296338749.006296296338749.006296296338749.0062962963

    38749.006990740738749.006990740738749.006990740738749.006990740738749.0069907407

    38749.007685185238749.007685185238749.007685185238749.007685185238749.0076851852

    38749.008379629638749.008379629638749.008379629638749.008379629638749.0083796296

    38749.009074074138749.009074074138749.009074074138749.009074074138749.0090740741

    38749.009768518538749.009768518538749.009768518538749.009768518538749.0097685185

    38749.01046296338749.01046296338749.01046296338749.01046296338749.010462963

    38749.011157407438749.011157407438749.011157407438749.011157407438749.0111574074

    38749.011851851938749.011851851938749.011851851938749.011851851938749.0118518519

    38749.012546296338749.012546296338749.012546296338749.012546296338749.0125462963

    38749.013240740738749.013240740738749.013240740738749.013240740738749.0132407407

    38749.013935185238749.013935185238749.013935185238749.013935185238749.0139351852

    38749.014629629638749.014629629638749.014629629638749.014629629638749.0146296296

    38749.015324074138749.015324074138749.015324074138749.015324074138749.0153240741

    38749.016018518538749.016018518538749.016018518538749.016018518538749.0160185185

    38749.01671296338749.01671296338749.01671296338749.01671296338749.016712963

    38749.017407407438749.017407407438749.017407407438749.017407407438749.0174074074

    38749.018101851838749.018101851838749.018101851838749.018101851838749.0181018518

    38749.018796296338749.018796296338749.018796296338749.018796296338749.0187962963

    38749.019490740738749.019490740738749.019490740738749.019490740738749.0194907407

    38749.020185185238749.020185185238749.020185185238749.020185185238749.0201851852

    38749.020879629638749.020879629638749.020879629638749.020879629638749.0208796296

    38749.021574074138749.021574074138749.021574074138749.021574074138749.0215740741

    38749.022268518538749.022268518538749.022268518538749.022268518538749.0222685185

    38749.02296296338749.02296296338749.02296296338749.02296296338749.022962963

    38749.023657407438749.023657407438749.023657407438749.023657407438749.0236574074

    38749.024351851938749.024351851938749.024351851938749.024351851938749.0243518519

    38749.025046296338749.025046296338749.025046296338749.025046296338749.0250462963

    38749.025740740738749.025740740738749.025740740738749.025740740738749.0257407407

    38749.026435185238749.026435185238749.026435185238749.026435185238749.0264351852

    38749.027129629638749.027129629638749.027129629638749.027129629638749.0271296296

    38749.027824074138749.027824074138749.027824074138749.027824074138749.0278240741

    38749.028518518538749.028518518538749.028518518538749.028518518538749.0285185185

    38749.02921296338749.02921296338749.02921296338749.02921296338749.029212963

    38749.029907407438749.029907407438749.029907407438749.029907407438749.0299074074

    38749.030601851938749.030601851938749.030601851938749.030601851938749.0306018519

    38749.031296296338749.031296296338749.031296296338749.031296296338749.0312962963

    38749.031990740738749.031990740738749.031990740738749.031990740738749.0319907407

    38749.032685185238749.032685185238749.032685185238749.032685185238749.0326851852

    38749.033379629638749.033379629638749.033379629638749.033379629638749.0333796296

    38749.034074074138749.034074074138749.034074074138749.034074074138749.0340740741

    38749.034768518538749.034768518538749.034768518538749.034768518538749.0347685185

    38749.03546296338749.03546296338749.03546296338749.03546296338749.035462963

    38749.036157407438749.036157407438749.036157407438749.036157407438749.0361574074

    38749.036851851938749.036851851938749.036851851938749.036851851938749.0368518519

    38749.037546296338749.037546296338749.037546296338749.037546296338749.0375462963

    38749.038240740738749.038240740738749.038240740738749.038240740738749.0382407407

    38749.038935185238749.038935185238749.038935185238749.038935185238749.0389351852

    38749.039629629638749.039629629638749.039629629638749.039629629638749.0396296296

    38749.040324074138749.040324074138749.040324074138749.040324074138749.0403240741

    38749.041018518538749.041018518538749.041018518538749.041018518538749.0410185185

    38749.04171296338749.04171296338749.04171296338749.04171296338749.041712963

    38749.042407407438749.042407407438749.042407407438749.042407407438749.0424074074

    38749.043101851938749.043101851938749.043101851938749.043101851938749.0431018519

    38749.043796296338749.043796296338749.043796296338749.043796296338749.0437962963

    38749.044490740738749.044490740738749.044490740738749.044490740738749.0444907407

    38749.045185185238749.045185185238749.045185185238749.045185185238749.0451851852

    38749.045879629638749.045879629638749.045879629638749.045879629638749.0458796296

    38749.046574074138749.046574074138749.046574074138749.046574074138749.0465740741

    38749.047268518538749.047268518538749.047268518538749.047268518538749.0472685185

    38749.04796296338749.04796296338749.04796296338749.04796296338749.047962963

    38749.048657407438749.048657407438749.048657407438749.048657407438749.0486574074

    38749.049351851838749.049351851838749.049351851838749.049351851838749.0493518518

    38749.050046296338749.050046296338749.050046296338749.050046296338749.0500462963

    38749.050740740738749.050740740738749.050740740738749.050740740738749.0507407407

    38749.051435185238749.051435185238749.051435185238749.051435185238749.0514351852

    38749.052129629638749.052129629638749.052129629638749.052129629638749.0521296296

    38749.052824074138749.052824074138749.052824074138749.052824074138749.0528240741

    38749.053518518538749.053518518538749.053518518538749.053518518538749.0535185185

    38749.055601851938749.055601851938749.055601851938749.055601851938749.0556018519

    38749.056990740738749.056990740738749.056990740738749.056990740738749.0569907407

    38749.058379629638749.058379629638749.058379629638749.058379629638749.0583796296

    38749.061851851938749.061851851938749.061851851938749.061851851938749.0618518519

    38749.062546296338749.062546296338749.062546296338749.062546296338749.0625462963

    38749.063240740738749.063240740738749.063240740738749.063240740738749.0632407407

    38749.063935185238749.063935185238749.063935185238749.063935185238749.0639351852

    38749.064629629638749.064629629638749.064629629638749.064629629638749.0646296296

    38749.065324074138749.065324074138749.065324074138749.065324074138749.0653240741

    38749.066018518538749.066018518538749.066018518538749.066018518538749.0660185185

    38749.06671296338749.06671296338749.06671296338749.06671296338749.066712963

    38749.067407407438749.067407407438749.067407407438749.067407407438749.0674074074

    38749.068101851938749.068101851938749.068101851938749.068101851938749.0681018519

    38749.068796296338749.068796296338749.068796296338749.068796296338749.0687962963

    38749.069490740738749.069490740738749.069490740738749.069490740738749.0694907407

    38749.070185185238749.070185185238749.070185185238749.070185185238749.0701851852

    38749.070879629638749.070879629638749.070879629638749.070879629638749.0708796296

    38749.071574074138749.071574074138749.071574074138749.071574074138749.0715740741

    38749.072268518538749.072268518538749.072268518538749.072268518538749.0722685185

    38749.07296296338749.07296296338749.07296296338749.07296296338749.072962963

    38749.073657407438749.073657407438749.073657407438749.073657407438749.0736574074

    38749.074351851938749.074351851938749.074351851938749.074351851938749.0743518519

    38749.075046296338749.075046296338749.075046296338749.075046296338749.0750462963

    38749.075740740738749.075740740738749.075740740738749.075740740738749.0757407407

    38749.076435185238749.076435185238749.076435185238749.076435185238749.0764351852

    38749.077129629638749.077129629638749.077129629638749.077129629638749.0771296296

    38749.077824074138749.077824074138749.077824074138749.077824074138749.0778240741

    38749.078518518538749.078518518538749.078518518538749.078518518538749.0785185185

    38749.07921296338749.07921296338749.07921296338749.07921296338749.079212963

    38749.079907407438749.079907407438749.079907407438749.079907407438749.0799074074

    38749.080601851838749.080601851838749.080601851838749.080601851838749.0806018518

    38749.081296296338749.081296296338749.081296296338749.081296296338749.0812962963

    38749.081990740738749.081990740738749.081990740738749.081990740738749.0819907407

    38749.082685185238749.082685185238749.082685185238749.082685185238749.0826851852

    38749.083379629638749.083379629638749.083379629638749.083379629638749.0833796296

    38749.084074074138749.084074074138749.084074074138749.084074074138749.0840740741

    38749.084768518538749.084768518538749.084768518538749.084768518538749.0847685185

    38749.08546296338749.08546296338749.08546296338749.08546296338749.085462963

    38749.086157407438749.086157407438749.086157407438749.086157407438749.0861574074

    38749.086851851938749.086851851938749.086851851938749.086851851938749.0868518519

    38749.087538749.087538749.087538749.087538749.0875

    38749.087546296338749.087546296338749.087546296338749.087546296338749.0875462963

    38749.087615740738749.087615740738749.087615740738749.087615740738749.0876157407

    38749.088240740738749.088240740738749.088240740738749.088240740738749.0882407407

    38749.088935185238749.088935185238749.088935185238749.088935185238749.0889351852

    38749.089629629638749.089629629638749.089629629638749.089629629638749.0896296296

    38749.090324074138749.090324074138749.090324074138749.090324074138749.0903240741

    38749.091018518538749.091018518538749.091018518538749.091018518538749.0910185185

    38749.09171296338749.09171296338749.09171296338749.09171296338749.091712963

    38749.092407407438749.092407407438749.092407407438749.092407407438749.0924074074

    38749.092407407438749.092407407438749.092407407438749.092407407438749.0924074074

    38749.092430555638749.092430555638749.092430555638749.092430555638749.0924305556

    38749.093101851938749.093101851938749.093101851938749.093101851938749.0931018519

    38749.093796296338749.093796296338749.093796296338749.093796296338749.0937962963

    38749.094490740738749.094490740738749.094490740738749.094490740738749.0944907407

    38749.095185185238749.095185185238749.095185185238749.095185185238749.0951851852

    38749.095879629638749.095879629638749.095879629638749.095879629638749.0958796296

    38749.096574074138749.096574074138749.096574074138749.096574074138749.0965740741

    38749.097268518538749.097268518538749.097268518538749.097268518538749.0972685185

    38749.09796296338749.09796296338749.09796296338749.09796296338749.097962963

    38749.098657407438749.098657407438749.098657407438749.098657407438749.0986574074

    38749.099351851938749.099351851938749.099351851938749.099351851938749.0993518519

    38749.100046296338749.100046296338749.100046296338749.100046296338749.1000462963

    38749.100740740738749.100740740738749.100740740738749.100740740738749.1007407407

    38749.100810185238749.100810185238749.100810185238749.100810185238749.1008101852

    38749.100833333338749.100833333338749.100833333338749.100833333338749.1008333333

    38749.101435185238749.101435185238749.101435185238749.101435185238749.1014351852

    38749.102129629638749.102129629638749.102129629638749.102129629638749.1021296296

    38749.102824074138749.102824074138749.102824074138749.102824074138749.1028240741

    38749.103518518538749.103518518538749.103518518538749.103518518538749.1035185185

    38749.10421296338749.10421296338749.10421296338749.10421296338749.104212963

    38749.104907407438749.104907407438749.104907407438749.104907407438749.1049074074

    38749.105601851938749.105601851938749.105601851938749.105601851938749.1056018519

    38749.106296296338749.106296296338749.106296296338749.106296296338749.1062962963

    38749.106990740738749.106990740738749.106990740738749.106990740738749.1069907407

    38749.107685185238749.107685185238749.107685185238749.107685185238749.1076851852

    38749.108379629638749.108379629638749.108379629638749.108379629638749.1083796296

    38749.109074074138749.109074074138749.109074074138749.109074074138749.1090740741

    38749.109768518538749.109768518538749.109768518538749.109768518538749.1097685185

    38749.11046296338749.11046296338749.11046296338749.11046296338749.110462963

    38749.111157407438749.111157407438749.111157407438749.111157407438749.1111574074

    38749.111851851838749.111851851838749.111851851838749.111851851838749.1118518518

    38749.112546296338749.112546296338749.112546296338749.112546296338749.1125462963

    38749.113240740738749.113240740738749.113240740738749.113240740738749.1132407407

    38749.113935185238749.113935185238749.113935185238749.113935185238749.1139351852

    38749.114629629638749.114629629638749.114629629638749.114629629638749.1146296296

    38749.115324074138749.115324074138749.115324074138749.115324074138749.1153240741

    38749.116018518538749.116018518538749.116018518538749.116018518538749.1160185185

    38749.11671296338749.11671296338749.11671296338749.11671296338749.116712963

    38749.117407407438749.117407407438749.117407407438749.117407407438749.1174074074

    38749.118101851938749.118101851938749.118101851938749.118101851938749.1181018519

    38749.118796296338749.118796296338749.118796296338749.118796296338749.1187962963

    38749.119490740738749.119490740738749.119490740738749.119490740738749.1194907407

    38749.120185185238749.120185185238749.120185185238749.120185185238749.1201851852

    38749.120879629638749.120879629638749.120879629638749.120879629638749.1208796296

    38749.121574074138749.121574074138749.121574074138749.121574074138749.1215740741

    38749.122268518538749.122268518538749.122268518538749.122268518538749.1222685185

    38749.12296296338749.12296296338749.12296296338749.12296296338749.122962963

    38749.123657407438749.123657407438749.123657407438749.123657407438749.1236574074

    38749.124351851938749.124351851938749.124351851938749.124351851938749.1243518519

    38749.125046296338749.125046296338749.125046296338749.125046296338749.1250462963

    38749.125740740738749.125740740738749.125740740738749.125740740738749.1257407407

    38749.126435185238749.126435185238749.126435185238749.126435185238749.1264351852

    38749.127129629638749.127129629638749.127129629638749.127129629638749.1271296296

    38749.127824074138749.127824074138749.127824074138749.127824074138749.1278240741

    38749.128518518538749.128518518538749.128518518538749.128518518538749.1285185185

    38749.12921296338749.12921296338749.12921296338749.12921296338749.129212963

    38749.129907407438749.129907407438749.129907407438749.129907407438749.1299074074

    38749.130601851938749.130601851938749.130601851938749.130601851938749.1306018519

    38749.131296296338749.131296296338749.131296296338749.131296296338749.1312962963

    38749.131990740738749.131990740738749.131990740738749.131990740738749.1319907407

    38749.132685185238749.132685185238749.132685185238749.132685185238749.1326851852

    38749.133379629638749.133379629638749.133379629638749.133379629638749.1333796296

    38749.134074074138749.134074074138749.134074074138749.134074074138749.1340740741

    38749.134768518538749.134768518538749.134768518538749.134768518538749.1347685185

    38749.13546296338749.13546296338749.13546296338749.13546296338749.135462963

    38749.136157407438749.136157407438749.136157407438749.136157407438749.1361574074

    38749.136851851938749.136851851938749.136851851938749.136851851938749.1368518519

    38749.137546296338749.137546296338749.137546296338749.137546296338749.1375462963

    38749.138240740738749.138240740738749.138240740738749.138240740738749.1382407407

    38749.138935185238749.138935185238749.138935185238749.138935185238749.1389351852

    38749.139629629638749.139629629638749.139629629638749.139629629638749.1396296296

    38749.140324074138749.140324074138749.140324074138749.140324074138749.1403240741

    38749.141018518538749.141018518538749.141018518538749.141018518538749.1410185185

    38749.14171296338749.14171296338749.14171296338749.14171296338749.141712963

    38749.142407407438749.142407407438749.142407407438749.142407407438749.1424074074

    38749.143101851838749.143101851838749.143101851838749.143101851838749.1431018518

    38749.143796296338749.143796296338749.143796296338749.143796296338749.1437962963

    38749.144490740738749.144490740738749.144490740738749.144490740738749.1444907407

    38749.145185185238749.145185185238749.145185185238749.145185185238749.1451851852

    38749.145879629638749.145879629638749.145879629638749.145879629638749.1458796296

    38749.146574074138749.146574074138749.146574074138749.146574074138749.1465740741

    38749.147268518538749.147268518538749.147268518538749.147268518538749.1472685185

    38749.14796296338749.14796296338749.14796296338749.14796296338749.147962963

    38749.148657407438749.148657407438749.148657407438749.148657407438749.1486574074

    38749.149351851938749.149351851938749.149351851938749.149351851938749.1493518519

    38749.150046296338749.150046296338749.150046296338749.150046296338749.1500462963

    38749.150740740738749.150740740738749.150740740738749.150740740738749.1507407407

    38749.151435185238749.151435185238749.151435185238749.151435185238749.1514351852

    38749.152129629638749.152129629638749.152129629638749.152129629638749.1521296296

    38749.152824074138749.152824074138749.152824074138749.152824074138749.1528240741

    38749.153518518538749.153518518538749.153518518538749.153518518538749.1535185185

    38749.15421296338749.15421296338749.15421296338749.15421296338749.154212963

    38749.154907407438749.154907407438749.154907407438749.154907407438749.1549074074

    38749.155601851938749.155601851938749.155601851938749.155601851938749.1556018519

    38749.156296296338749.156296296338749.156296296338749.156296296338749.1562962963

    38749.156990740738749.156990740738749.156990740738749.156990740738749.1569907407

    38749.157685185238749.157685185238749.157685185238749.157685185238749.1576851852

    38749.158379629638749.158379629638749.158379629638749.158379629638749.1583796296

    38749.159074074138749.159074074138749.159074074138749.159074074138749.1590740741

    38749.159768518538749.159768518538749.159768518538749.159768518538749.1597685185

    38749.16046296338749.16046296338749.16046296338749.16046296338749.160462963

    38749.161157407438749.161157407438749.161157407438749.161157407438749.1611574074

    38749.161851851938749.161851851938749.161851851938749.161851851938749.1618518519

    38749.162546296338749.162546296338749.162546296338749.162546296338749.1625462963

    38749.163240740738749.163240740738749.163240740738749.163240740738749.1632407407

    38749.163935185238749.163935185238749.163935185238749.163935185238749.1639351852

    38749.164629629638749.164629629638749.164629629638749.164629629638749.1646296296

    38749.165324074138749.165324074138749.165324074138749.165324074138749.1653240741

    38749.166018518538749.166018518538749.166018518538749.166018518538749.1660185185

    38749.16671296338749.16671296338749.16671296338749.16671296338749.166712963

    38749.167407407438749.167407407438749.167407407438749.167407407438749.1674074074

    38749.168101851938749.168101851938749.168101851938749.168101851938749.1681018519

    38749.168796296338749.168796296338749.168796296338749.168796296338749.1687962963

    38749.169490740738749.169490740738749.169490740738749.169490740738749.1694907407

    38749.170185185238749.170185185238749.170185185238749.170185185238749.1701851852

    38749.170879629638749.170879629638749.170879629638749.170879629638749.1708796296

    38749.171574074138749.171574074138749.171574074138749.171574074138749.1715740741

    38749.172268518538749.172268518538749.172268518538749.172268518538749.1722685185

    38749.17296296338749.17296296338749.17296296338749.17296296338749.172962963

    38749.173657407438749.173657407438749.173657407438749.173657407438749.1736574074

    38749.174351851838749.174351851838749.174351851838749.174351851838749.1743518518

    38749.175046296338749.175046296338749.175046296338749.175046296338749.1750462963

    38749.175740740738749.175740740738749.175740740738749.175740740738749.1757407407

    38749.176435185238749.176435185238749.176435185238749.176435185238749.1764351852

    38749.177129629638749.177129629638749.177129629638749.177129629638749.1771296296

    38749.177824074138749.177824074138749.177824074138749.177824074138749.1778240741

    38749.178518518538749.178518518538749.178518518538749.178518518538749.1785185185

    38749.17921296338749.17921296338749.17921296338749.17921296338749.179212963

    38749.179907407438749.179907407438749.179907407438749.179907407438749.1799074074

    38749.180601851938749.180601851938749.180601851938749.180601851938749.1806018519

    38749.181296296338749.181296296338749.181296296338749.181296296338749.1812962963

    38749.181990740738749.181990740738749.181990740738749.181990740738749.1819907407

    38749.182685185238749.182685185238749.182685185238749.182685185238749.1826851852

    38749.183379629638749.183379629638749.183379629638749.183379629638749.1833796296

    38749.184074074138749.184074074138749.184074074138749.184074074138749.1840740741

    38749.184768518538749.184768518538749.184768518538749.184768518538749.1847685185

    38749.18546296338749.18546296338749.18546296338749.18546296338749.185462963

    38749.186157407438749.186157407438749.186157407438749.186157407438749.1861574074

    38749.186851851938749.186851851938749.186851851938749.186851851938749.1868518519

    38749.187546296338749.187546296338749.187546296338749.187546296338749.1875462963

    38749.188240740738749.188240740738749.188240740738749.188240740738749.1882407407

    38749.188935185238749.188935185238749.188935185238749.188935185238749.1889351852

    38749.189629629638749.189629629638749.189629629638749.189629629638749.1896296296

    38749.190324074138749.190324074138749.190324074138749.190324074138749.1903240741

    38749.191018518538749.191018518538749.191018518538749.191018518538749.1910185185

    38749.19171296338749.19171296338749.19171296338749.19171296338749.191712963

    38749.192407407438749.192407407438749.192407407438749.192407407438749.1924074074

    38749.193101851938749.193101851938749.193101851938749.193101851938749.1931018519

    38749.193796296338749.193796296338749.193796296338749.193796296338749.1937962963

    38749.194490740738749.194490740738749.194490740738749.194490740738749.1944907407

    38749.195185185238749.195185185238749.195185185238749.195185185238749.1951851852

    38749.195879629638749.195879629638749.195879629638749.195879629638749.1958796296

    38749.196574074138749.196574074138749.196574074138749.196574074138749.1965740741

    38749.197268518538749.197268518538749.197268518538749.197268518538749.1972685185

    38749.19796296338749.19796296338749.19796296338749.19796296338749.197962963

    38749.198657407438749.198657407438749.198657407438749.198657407438749.1986574074

    38749.199351851938749.199351851938749.199351851938749.199351851938749.1993518519

    38749.200046296338749.200046296338749.200046296338749.200046296338749.2000462963

    38749.200740740738749.200740740738749.200740740738749.200740740738749.2007407407

    38749.201435185238749.201435185238749.201435185238749.201435185238749.2014351852

    38749.202129629638749.202129629638749.202129629638749.202129629638749.2021296296

    38749.202824074138749.202824074138749.202824074138749.202824074138749.2028240741

    38749.203518518538749.203518518538749.203518518538749.203518518538749.2035185185

    38749.20421296338749.20421296338749.20421296338749.20421296338749.204212963

    38749.204907407438749.204907407438749.204907407438749.204907407438749.2049074074

    38749.205601851838749.205601851838749.205601851838749.205601851838749.2056018518

    38749.206296296338749.206296296338749.206296296338749.206296296338749.2062962963

    38749.206990740738749.206990740738749.206990740738749.206990740738749.2069907407

    SaO2 %

    HR beats/min

    PCA Bolus

    ETCO2 mmHg

    RR breaths/min

    95

    88

    40

    22

    96

    87

    37

    21

    96

    82

    39

    19

    96

    81

    40

    19

    95

    82

    39

    96

    87

    40

    17

    96

    85

    41

    20

    95

    83

    42

    20

    95

    87

    42

    22

    95

    84

    43

    20

    96

    84

    41

    18

    96

    81

    38

    19

    95

    83

    40

    21

    95

    80

    41

    20

    94

    81

    42

    20

    94

    83

    43

    20

    93

    84

    43

    21

    94

    81

    43

    19

    94

    81

    42

    20

    93

    84

    43

    20

    93

    83

    41

    17

    94

    82

    39

    20

    94

    82

    43

    21

    95

    83

    43

    17

    94

    82

    43

    21

    96

    87

    43

    21

    96

    81

    42

    17

    95

    82

    43

    19

    94

    82

    45

    20

    95

    83

    44

    20

    95

    82

    42

    19

    95

    83

    42

    19

    94

    84

    41

    20

    95

    87

    41

    20

    96

    82

    42

    19

    95

    84

    41

    18

    95

    83

    42

    19

    95

    84

    42

    21

    95

    83

    42

    21

    95

    83

    40

    18

    95

    82

    40

    19

    95

    85

    42

    20

    95

    84

    42

    20

    96

    87

    41

    22

    96

    86

    42

    18

    95

    85

    42

    20

    94

    86

    42

    22

    95

    84

    42

    20

    95

    85

    41

    20

    97

    89

    38

    22

    96

    86

    39

    20

    95

    86

    40

    20

    94

    86

    41

    20

    95

    86

    41

    20

    96

    90

    41

    21

    95

    85

    41

    21

    95

    84

    41

    19

    95

    83

    40

    19

    94

    84

    40

    18

    95

    83

    41

    20

    94

    85

    42

    19

    95

    85

    42

    20

    95

    85

    42

    21

    94

    86

    42

    21

    95

    85

    41

    18

    95

    86

    41

    21

    96

    88

    41

    18

    94

    86

    40

    20

    95

    85

    40

    20

    94

    86

    40

    20

    93

    86

    41

    20

    94

    85

    40

    19

    93

    88

    38

    18

    95

    85

    41

    19

    94

    86

    39

    22

    95

    86

    38

    19

    95

    85

    39

    20

    94

    85

    40

    20

    96

    86

    37

    23

    95

    88

    39

    22

    97

    84

    38

    21

    96

    88

    37

    23

    95

    85

    40

    20

    94

    86

    37

    20

    93

    86

    39

    20

    93

    85

    36

    20

    93

    84

    38

    20

    95

    85

    40

    19

    93

    85

    40

    17

    94

    84

    37

    18

    94

    84

    39

    18

    93

    84

    40

    19

    96

    90

    38

    20

    96

    86

    39

    16

    94

    83

    38

    19

    93

    83

    41

    20

    93

    83

    41

    20

    92

    85

    41

    20

    92

    85

    43

    19

    92

    87

    42

    19

    92

    86

    41

    19

    92

    83

    41

    19

    91

    81

    40

    19

    92

    83

    45

    18

    92

    85

    37

    20

    94

    85

    37

    19

    92

    83

    42

    19

    91

    83

    60

    42

    20

    92

    84

    42

    19

    92

    82

    42

    19

    92

    82

    42

    20

    92

    85

    42

    19

    93

    83

    42

    20

    92

    85

    42

    20

    91

    83

    41

    19

    93

    82

    41

    18

    91

    83

    42

    18

    92

    82

    41

    20

    90

    83

    42

    18

    92

    82

    42

    20

    92

    83

    42

    20

    92

    83

    42

    20

    93

    87

    41

    21

    93

    82

    40

    19

    92

    82

    42

    20

    91

    83

    40

    19

    94

    81

    42

    19

    93

    83

    41

    17

    92

    83

    42

    20

    93

    81

    41

    19

    93

    82

    43

    20

    92

    81

    42

    19

    92

    81

    38

    20

    93

    81

    40

    17

    93

    82

    40

    20

    92

    81

    40

    19

    93

    83

    42

    19

    93

    81

    42

    19

    94

    81

    40

    19

    94

    82

    39

    19

    94

    80

    37

    19

    93

    82

    40

    20

    93

    81

    40

    19

    93

    87

    41

    22

    96

    82

    40

    20

    95

    79

    41

    18

    94

    80

    42

    19

    94

    78

    42

    19

    94

    81

    43

    17

    93

    82

    42

    16

    94

    81

    40

    18

    94

    80

    42

    18

    94

    80

    42

    19

    93

    79

    43

    19

    94

    81

    43

    19

    94

    81

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    82

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    19

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    81

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    19

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    81

    42

    20

    94

    81

    41

    19

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    81

    42

    19

    95

    83

    40

    19

    97

    80

    42

    21

    97

    82

    41

    21

    96

    80

    41

    20

    96

    83

    40

    22

    96

    84

    41

    23

    96

    79

    42

    21

    95

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    20

    95

    79

    42

    20

    94

    82

    41

    20

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    81

    43

    19

    95

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    41

    19

    94

    81

    43

    20

    95

    84

    43

    22

    95

    83

    43

    21

    95

    81

    44

    20

    94

    79

    60

    45

    19

    94

    80

    44

    18

    94

    81

    42

    19

    95

    83

    45

    19

    94

    81

    43

    18

    94

    83

    46

    17

    96

    82

    44

    19

    95

    80

    44

    17

    94

    79

    46

    18

    95

    81

    42

    19

    95

    79

    45

    17

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    19

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    20

    94

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    19

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    20

    96

    80

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    21

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    21

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    96

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    43

    21

    96

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    20

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    16

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    85

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    79

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    17

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    79

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    79

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    19

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    45

    17

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    79

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    17

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    45

    17

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    82

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    18

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    47

    18

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    78

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    17

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    46

    17

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    77

    47

    16

    94

    78

    47

    14

    95

    78

    46

    15

    95

    77

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    16

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    95

    75

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    17

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    79

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    77

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    17

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    76

    45

    16

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    17

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    77

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    77

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    79

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    11

    93

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    96

    77

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    9

    96

    77

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    10

    94

    77

    48

    11

    Figure 5b.

    Figure 5b.

    38751.781493055638751.781493055638751.781493055638751.781493055638751.7814930556

    38751.782881944438751.782881944438751.782881944438751.782881944438751.7828819444

    38751.783576388938751.783576388938751.783576388938751.783576388938751.7835763889

    38751.784270833338751.784270833338751.784270833338751.784270833338751.7842708333

    38751.784965277838751.784965277838751.784965277838751.784965277838751.7849652778

    38751.785659722238751.785659722238751.785659722238751.785659722238751.7856597222

    38751.786354166738751.786354166738751.786354166738751.786354166738751.7863541667

    38751.787048611138751.787048611138751.787048611138751.787048611138751.7870486111

    38751.787743055638751.787743055638751.787743055638751.787743055638751.7877430556

    38751.788437538751.788437538751.788437538751.788437538751.7884375

    38751.789131944438751.789131944438751.789131944438751.789131944438751.7891319444

    38751.789826388938751.789826388938751.789826388938751.789826388938751.7898263889

    38751.790520833338751.790520833338751.790520833338751.790520833338751.7905208333

    38751.791215277838751.791215277838751.791215277838751.791215277838751.7912152778

    38751.791909722238751.791909722238751.791909722238751.791909722238751.7919097222

    38751.792604166738751.792604166738751.792604166738751.792604166738751.7926041667

    38751.793298611138751.793298611138751.793298611138751.793298611138751.7932986111

    38751.793993055638751.793993055638751.793993055638751.793993055638751.7939930556

    38751.794687538751.794687538751.794687538751.794687538751.7946875

    38751.795381944438751.795381944438751.795381944438751.795381944438751.7953819444

    38751.796076388938751.796076388938751.796076388938751.796076388938751.7960763889

    38751.796770833338751.796770833338751.796770833338751.796770833338751.7967708333

    38751.797465277838751.797465277838751.797465277838751.797465277838751.7974652778

    38751.798159722238751.798159722238751.798159722238751.798159722238751.7981597222

    38751.798854166738751.798854166738751.798854166738751.798854166738751.7988541667

    38751.799548611138751.799548611138751.799548611138751.799548611138751.7995486111

    38751.800243055638751.800243055638751.800243055638751.800243055638751.8002430556

    38751.800937538751.800937538751.800937538751.800937538751.8009375

    38751.801631944438751.801631944438751.801631944438751.801631944438751.8016319444

    38751.802326388938751.802326388938751.802326388938751.802326388938751.8023263889

    38751.803020833338751.803020833338751.803020833338751.803020833338751.8030208333

    38751.803715277838751.803715277838751.803715277838751.803715277838751.8037152778

    38751.805127314838751.805127314838751.805127314838751.805127314838751.8051273148

    38751.805358796338751.805358796338751.805358796338751.805358796338751.8053587963

    38751.805798611138751.805798611138751.805798611138751.805798611138751.8057986111

    38751.806481481538751.806481481538751.806481481538751.806481481538751.8064814815

    38751.80702546338751.80702546338751.80702546338751.80702546338751.807025463

    38751.807881944438751.807881944438751.807881944438751.807881944438751.8078819444

    38751.808576388938751.808576388938751.808576388938751.808576388938751.8085763889

    38751.809270833338751.809270833338751.809270833338751.809270833338751.8092708333

    38751.809965277838751.809965277838751.809965277838751.809965277838751.8099652778

    38751.810659722238751.810659722238751.810659722238751.810659722238751.8106597222

    38751.811354166738751.811354166738751.811354166738751.811354166738751.8113541667

    38751.812048611138751.812048611138751.812048611138751.812048611138751.8120486111

    38751.812870370438751.812870370438751.812870370438751.812870370438751.8128703704

    38751.813437538751.813437538751.813437538751.813437538751.8134375

    38751.814131944438751.814131944438751.814131944438751.814131944438751.8141319444

    38751.814826388938751.814826388938751.814826388938751.814826388938751.8148263889

    38751.815520833338751.815520833338751.815520833338751.815520833338751.8155208333

    38751.816215277838751.816215277838751.816215277838751.816215277838751.8162152778

    38751.816770833338751.816770833338751.816770833338751.816770833338751.8167708333

    38751.817604166738751.817604166738751.817604166738751.817604166738751.8176041667

    38751.818298611138751.818298611138751.818298611138751.818298611138751.8182986111

    38751.818993055638751.818993055638751.818993055638751.818993055638751.8189930556

    38751.819687538751.819687538751.819687538751.819687538751.8196875

    38751.82016203738751.82016203738751.82016203738751.82016203738751.820162037

    38751.821076388938751.821076388938751.821076388938751.821076388938751.8210763889

    38751.821770833338751.821770833338751.821770833338751.821770833338751.8217708333

    38751.822418981538751.822418981538751.822418981538751.822418981538751.8224189815

    38751.823159722238751.823159722238751.823159722238751.823159722238751.8231597222

    38751.823854166738751.823854166738751.823854166738751.823854166738751.8238541667

    38751.824548611138751.824548611138751.824548611138751.824548611138751.8245486111

    38751.825682870438751.825682870438751.825682870438751.825682870438751.8256828704

    38751.825763888938751.825763888938751.825763888938751.825763888938751.8257638889

    38751.826631944438751.826631944438751.826631944438751.826631944438751.8266319444

    38751.827326388938751.827326388938751.827326388938751.827326388938751.8273263889

    38751.828020833338751.828020833338751.828020833338751.828020833338751.8280208333

    38751.828715277838751.828715277838751.828715277838751.828715277838751.8287152778

    38751.829409722238751.829409722238751.829409722238751.829409722238751.8294097222

    38751.830104166738751.830104166738751.830104166738751.830104166738751.8301041667

    38751.830798611138751.830798611138751.830798611138751.830798611138751.8307986111

    38751.831493055638751.831493055638751.831493055638751.831493055638751.8314930556

    38751.832418981538751.832418981538751.832418981538751.832418981538751.8324189815

    38751.832638888938751.832638888938751.832638888938751.832638888938751.8326388889

    38751.832881944438751.832881944438751.832881944438751.832881944438751.8328819444

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.833368055638751.833368055638751.833368055638751.833368055638751.8333680556

    38751.834270833338751.834270833338751.834270833338751.834270833338751.8342708333

    38751.834965277838751.834965277838751.834965277838751.834965277838751.8349652778

    38751.835659722238751.835659722238751.835659722238751.835659722238751.8356597222

    38751.836354166738751.836354166738751.836354166738751.836354166738751.8363541667

    38751.837048611138751.837048611138751.837048611138751.837048611138751.8370486111

    38751.837743055638751.837743055638751.837743055638751.837743055638751.8377430556

    HR beats/min

    SaO2 %

    "Code Blue"

    RR breaths/min

    ETCO2 mmHg

    79

    94

    28

    29

    77

    93

    27

    30

    76

    95

    27

    30

    75

    92

    26

    31

    78

    95

    24

    31

    83

    93

    24

    28

    79

    94

    26

    28

    80

    94

    25

    27

    82

    94

    28

    28

    81

    96

    27

    30

    79

    94

    27

    28

    83

    93

    26

    27

    83

    94

    27

    29

    84

    92

    27

    28

    82

    94

    26

    27

    85

    91

    28

    29

    87

    90

    28

    27

    83

    90

    25

    30

    86

    92

    28

    28

    84

    93

    27

    30

    85

    94

    27

    24

    85

    93

    26

    24

    83

    90

    26

    26

    82

    91

    25

    23

    82

    92

    27

    26

    81

    94

    27

    25

    85

    92

    26

    27

    86

    93

    29

    27

    81

    94

    27

    28

    75

    91

    30

    27

    84

    93

    29

    29

    89

    93

    28

    27

    92

    93

    29

    28

    89

    91

    32

    26

    86

    90

    32

    26

    90

    93

    34

    25

    92

    92

    34

    25

    92

    93

    35

    24

    90

    93

    38

    26

    94

    94

    39

    29

    91

    94

    39

    24

    94

    92

    38

    26

    93

    93

    38

    23

    93

    90

    37

    21

    96

    93

    35

    24

    89

    94

    38

    24

    97

    93

    46

    22

    98

    90

    46

    24

    99

    92

    42

    23

    101

    94

    35

    24

    98

    91

    38

    26

    93

    89

    36

    22

    97

    89

    36

    21

    86

    90

    42

    21

    99

    89

    44

    22

    102

    88

    41

    22

    103

    89

    42

    21

    105

    92

    37

    22

    109

    91

    37

    22

    100

    90

    42

    22

    103

    86

    45

    21

    102

    87

    50

    22

    116

    85

    48

    19

    114

    89

    44

    22

    112

    84

    45

    18

    115

    83

    47

    16

    120

    85

    48

    18

    119

    84

    43

    19

    117

    87

    39

    21

    119

    86

    43

    19

    121

    88

    45

    18

    124

    85

    40

    17

    123

    83

    37

    21

    122

    83

    30

    22

    119

    82

    32

    19

    132

    80

    123

    25

    17

    132

    80

    113

    25

    17

    132

    80

    103

    25

    17

    132

    80

    93

    25

    17

    132

    80

    83

    25

    17

    132

    80

    73

    25

    17

    132

    80

    63

    25

    17

    132

    80

    53

    25

    17

    132

    80

    43

    25

    17

    132

    80

    33

    25

    17

    132

    80

    23

    25

    17

    129

    77

    24

    20

    133

    75

    21

    19

    133

    70

    23

    20

    136

    74

    24

    18

    132

    78

    25

    24

    129

    72

    26

    21

  • O2 supplementation may actually worsen things!

    [16]

  • 0

    20

    40

    60

    80

    100

    120

    1/31/06 23:45 2/1/06 0:57 2/1/06 2:09 2/1/06 3:21 2/1/06 4:33

    SaO2 %

    HR beats/min

    PCA Bolus

    ETCO2 mmHg

    RR breaths/min

    Continuous capnography/oximetry monitoring during PCA

    Chart1

    38749.000046296338749.000046296338749.000046296338749.000046296338749.0000462963

    38749.000740740738749.000740740738749.000740740738749.000740740738749.0007407407

    38749.001435185238749.001435185238749.001435185238749.001435185238749.0014351852

    38749.002129629638749.


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