Natural speed please
Consequences of Equipment-related Artifacts
Technical:
- Erroneous alarm activation
- Inability to obtain satisfactory electrocardiogram
- Unnecessary repeated electrocardiographic measurements
- Unnecessary electrical checking of outlets, leakage, grounding, and safety standards
- Unnecessary unplugging, replacement, and electrical checking of other monitors and equipment
Physician related (no harm to patient):
- Confusion and puzzling to various staff
- Emergency call for physician to attend
- Interference in the clinical evaluation, monitoring, and diagnosis
- Failure to evaluate the effects of interventions
- Unnecessary investigations: electrolytes, arterial blood gases
- Cardiology consultation
- Brief interruption of the therapy or surgical procedure
- Pulmonary artery catheter taken out
Patient related (near misses or harm to the patients):
- Malfunction of ESWL58 and IABP37 due to interference with the triggering based on R wave
- Unnecessary ICU admission
- Wrong diagnosis: malfunctioning of pacemaker in the absence of pacemaker or other various arrhythmia
- Return of symptoms if electrostimulators are deactivated
- Unnecessary therapeutic interventions
- Fluid bolus
- Valsalva maneuver
- Electrolytes (potassium, magnesium) supplement
- Antiarrhythmic Lidocaine and other antiarrythmics
- Adenosine (repeated four times)
- Amiodarone for pseudo–atrial fibrillation
- Esmolol for supraventricular tachycardia
- Synchronized DC shocks
- DC shocks from ICD
Medicolegal/administrative Administrative problems:
- closure of the affected beds
- Documentation in notes and charting of electrocardiogram with artifacts
Solutions
Certain surgical environments and procedures (e.g., neurosurgery) are more likely to generate artifact than others, and suspicion of this possibility is an important part of problem solving by the physician.
Unrecognizable interpretable interference of short-term duration may not necessitate any action, although it can trigger unnecessary alarms. Recognized artifacts of longer duration require analytical correction to monitor and diagnose genuine electrocardiographic changes. The technological standard and quality of medical devices should be to the level specified by national and professional organizations. Periodic professional maintenance for operational and electrical safety, of not only the electrocardiographic monitors but all the electrical equipment in the operating room and ICU, remains essential.
General Measures
Appropriate skin preparation, electrode and lead placement, and vigilance against broken or misplaced leads, low batteries, or unplugged monitors should be the responsibility of and easily corrected by the clinician, before any therapeutic intervention for arrhythmia. Loose electrodes (e.g., application of sterilizing prep solutions) will cause impedance imbalance and ultimately will decrease the system’s common-mode rejection capabilities. Physical movement of electrodes should be watched for and prevented during use of high-risk equipment such as high-frequency oscillatory ventilation. Electrocardiographic electrodes can be positioned away from the stimulating needle electrodes of SSEP, e.g., moving the electrocardiographic electrode from the forearm to the shoulder removed repetitive artifacts associated with SSEP stimulation. Marco and Rice suggested careful insertion and monitoring of stimulating needle electrodes, together with care in the arrangement of stimulator cables for SSEP monitoring. Use of esophageal electrocardiographic probes may be useful in eliminating the occurrence of SSEP related interference in electrocardiographic trace.
