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Monitoring in Anesthesia
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ContentsIntroduction
What is monitoring?Which, Why and How to monitor?
Level of monitoringStandards for basic intraoperative
monitoring ( ASA)Systematic monitoringConclusion
Monitoring: A Definition ... interpret available clinical data to help
recognize present or future mishaps or unfavorable system conditions
... not restricted to anesthesia (change “clinical data” above to “system data” to apply to aircraft and nuclear power plants)
What is monitoring?
to monere (การู้เฝ้�ารู้ะวั�ง, การู้เต$อนภั�ย) Physiologic parameter & Patient safety parameter Clinical skills & Monitoring equipment Data collection, interpretation, evaluation, decision Problem seeking, Severity assessment, Therapeutic
assessment, Evaluation of Anesthetic interventions
Patient Monitoring and Management
Involves …Things you measure (physiological measurement, such as BP or HR)
Things you observe (e.g. observation of pupils)
Planning to avoid trouble (e.g. planning induction of anesthesia or planning
extubation)
Inferring diagnoses (e.g. unilateral air entry may mean endobronchial
intubation)
Planning to get out of trouble (e.g. differential diagnosis and response
algorithm formulation)
Level of monitoring Routine / Specialize / Extensive Non-equipment / Non-invasive / Minimally invasive
/ Penetrating / Invasive / Highly invasive Systematic
Respiratory / Cardiovascular / Temperature/Fetal Neurological / Neuro-muscular / Volume status & Renal
Standards for basic intraoperative monitoring
( ASA)
Standards for basic intraoperative monitoring
( ASA : American Society of Anesthesiologists)
Standard I Qualified anesthesia personnel shall be present in the
room throughout the conduct of all GA, RA, MAC
Standard II During all anesthetics, the patient’s respiratory
(ventilation, oxygenation), circulation and temperature shall be continually evaluated
Monitoring in the Past Visual monitoring of
respiration and overall clinical appearance
Finger on pulse Blood pressure
(sometimes)
Monitoring in the Past
Finger on the pulse
Harvey Cushing Not just a famous neurosurgeon …
but the father of anesthesia monitoring Invented and popularized the
anesthetic chart Recorded both BP and HR Emphasized the relationship
between vital signs and neurosurgical events ( increased intracranial pressure leads to hypertension and bradycardia )
Examples of Multiparameter Patient MonitorsExamples of Multiparameter Patient Monitors
Some Specialized Patient MonitorsSome Specialized Patient Monitors
Depth of Anesthesia Monitor
Evoked Potential Monitor
Transesophageal Echocardiography
Cardiovascular monitoring Routine monitoring
Cardiac activity Non-invasive blood pressure ( NIBP )Non-invasive blood pressure ( NIBP ) Electrocardiography ( ECG )Electrocardiography ( ECG )
Advanced monitoringDirect arterial blood pressureCardiac filling pressure monitor
Central venous pressurePulmonary capillary wedge pressure
Cardiovascular monitoring
ElectrocardiographyCardiac activityArrhythmia: Lead IIMyocardial ischemia: ECG criteriaElectrolyte imbalancePacemaker function
Cardiovascular monitoring การู้บ่�าน การู้บ่�าน ECGECG 1. การู้ต-ด้ lead II, modified V5 2. การู้แปรู้ผล สาเห้ต� การู้รู้�กษา-arrhythmia : bradycardia, tachycardia, AF,
PVC, VT, VF-Myocardial ischemia-electrolyte imbalance
Cardiovascular monitoring
Non-invasive blood pressure (NIBP) Cuff: width 120-150 % limb diameter, air bladder includes
more than halfway around limb Manometer: aneroid, mercury Detector: manual, automated
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Cardiovascular monitoring Non-invasive blood pressure
Inaccurate: cuff size, inflated pressure, shivering, cardiac arrhythmia, severe vasoconstriction
Proper application Narrow cuff Loose cuff
Cardiovascular monitoring Direct arterial pressure monitor
Indications Continuous blood pressure monitor:
anticipated cardiovascular instability, direct manipulation of cardiovascular system, inability to accurate measurement directly
Frequent arterial blood sampling: ABG, Acid-base / electrolyte / glucose disturbance, Coagulopathies
Cardiovascular monitoring Direct arterial pressure monitor
ContraindicationsLocal infectionImpaired blood circulation: Raynaud’s
phenomenon, DMRisks of thrombosis: hyperlipidemia, previous
brachial artery cannulation Modified Allen’s test ??? ( การู้บ่�านข้�อที่!%เที่�าไรู้
แล�วัค์ะ)
Cardiovascular monitoring Direct arterial pressure monitor
Complications Direct trauma: AV-fistula, Aneurysm Hematoma Infections Thrombosis Embolization Massive blood loss
Cardiovascular monitoring Cardiac filling pressure monitor
Frank-Starling curve: optimum Preload maximize ventricular performance (Stroke volume, CO.)
Preload = Myocardial fiber length (2.2 micron)LV Preload LVEDV LVEDP LAP PCWP
PAP RVP RAP CVP Myocardium function, LV compliance, Mitral valve, Airway
pressure, Pulmonary vascular resistance, Pulmonic valve, Tricuspid valve
Cardiovascular monitoring Cardiac filling pressure monitor
LV Preload LVEDV LVEDP LAP PCWP PAP LVEDP RVEDP RAP CVP
Cardiovascular monitoring Cardiac filling pressure monitor
PCWP: Pulmonary capillary wedge pressure CVP: Central venous pressure
Cardiovascular monitoring PCWP: Pulmonary capillary wedge pressure CVP: Central venous pressure
Fluid Challenge testFluid Challenge test to optimize preload and maximize Cardiac performance
Respiratory monitoring Ventilatory monitoring Oxygenation monitoring Machine and Circuit monitoring
Clinical skillsMonitoring devices
Ventilatory monitoring Clinical skills
Direct observation: rate, rhythm, volume of respirationAuscultation: precordial, esophageal stethoscopePalpation: reservoir bag movement
Monitoring devicesSpirometerAirway pressure manometerCircuit disconnection alarm
Ventilatory monitoring Capnometer (End-tidal CO(End-tidal CO22 analysis analysis)
relationship with PaCO2 : ETCO2 < PaCO2 ~ 3-6 mmHgmainly depends on dead space ventilationnormal value 30 – 35 mmHg Infrared absorption spectrographyMain-stream VS. Side-stream
Ventilatory monitoring Capnogram : normal curve
1. Dead space air (no CO2)
2. Mixed bronchus & alveolus air (CO2 upstroke)
3. Alveolus air (CO2 plateau)Inspiration ETCO2
12
3
Ventilatory monitoring Capnometer (End-tidal CO2 analysis)
Most useful in detection of Esophageal intubation, airway or circuit disconnection
Useful in CO2 rebreathing, partial recovery of neuro-muscular blockade, good predictor of successful CPR
การู้บ่�าน (เข้!ยน waveform of ET-CO2 และสาเห้ต�) Capnograph-esophageal intubation-bronchial intubation-airway obstruction-circuit disconnect-circuit leakage-partial rebreathing-spontaneous breathing (recovary of neuromuscular blockade)-hypoventilation
Oxygenation monitoring Clinical skills
Direct observation: impaired mental function, sympathetic overactivities, appearance(+ cyanosis)
Auscultation: wheezing, crepitation Monitoring devices
Arterial blood gas analysisPercutaneous O2 measurementPulse oximeter
Oxygenation monitoring
Pulse oximeterPercent of oxyhemoglobin
/ total hemoglobinOxyhemoglobin absorp
940 nm.Deoxyhemoglobin absorp
660 nm.Caution: SpO2 PaO2
Oxygenation monitoring Pulse oximeterPulse oximeter
SpO2 correlates with PaO2 as in Oxygen-hemoglobin dissociation curve
SpO2 90 PaO2 60 mmHg
(moderate hypoxemia)
75 40 mmHg
(mixed venous oxygen sat.)
50 27 mmHg
(P50)
Oxygenation monitoring Pulse oximeter artifacts
Abnormal hemoglobin: COHb, MetHb, HbFDye: Methylene blueAnemiaAmbient lightArterial saturationBlood flowMotionNail polishElectro-cautery
การู้บ่�าน Wave form Pulse oximeter Pulse oximeter artifacts กรู้ะที่บ่ต�อการู้
แปรู้ผลอย�างไรู้ Cause of Rt-Lt shift of oxygen-
hemoglobin dissociation curve
Machine & circuit monitoring Safety system
DISS, PISS, Quick disconnection adaptorOxygen fail-safe valve, Oxygen supply failure alarm
Oxygen analyzer Airway gas composition
Clinical skills: flowmeters, vaporizersMonitoring devices: Infrared spectrometer
Depth of Anesthesia Clinical Signs
eye signs
respiratory signs
cardiovascular signs
CNS signs
EEG monitoring
Facial EMG monitoring (experimental)
Esophageal contractility (obsolete)
Neurologic monitoringDepth of anesthesia ( BIS )EEGEvoked potentialsCerebral blood flow Intracranial pressure
Neuromuscular monitoringClinical skillsMonitoring device :
PERIPHERAL NERVE STIMULATOR
Volume status and renal monitoring
Estimate blood lossUrine outputHemodynamic stability
Volume status and renal monitoring
Estimate blood lossUrine outputHemodynamic stability
Electrolyte / Metabolic monitoring
Fluid balance Sugar Electrolytes Acid-base balance
Coagulation Monitoring
PT / PTT / INR ACT Platelet counts Factor assays TEG Clinical sign
Temperature monitoring
4 mechanism of heat lossPerioperative hypothermia (BT<36)Core temperature : nasopharynx, esophageal,
tympanic membrane, pulmonary a. catheter, bladder, rectum
Temperature Monitoring
Rationale for use detect/prevent hypothermia monitor deliberate hypothermia adjunct to diagnosing MH monitoring CPB cooling/rewarming
Temperature monitoring
Deleterious effects of hypothermia -cardiac dysrhythmia -increased PVR -Lt. shift of the Oxygen-hemoglobin dissociation curve -reversible coagulopathy (platelet dysfunction) -postoperative protein catabolism and stress response -altered mental status -impaired renal function -decreased drug metabolism -poor wound healing
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