C1-2 MODUL – Non-invasive monitoring; Invasive hemodinamic monitoring C3-4 MODUL – Laparotomy, enterotomy, Intestinal suture, Diagnostic peritoneal lavage, Chest tube insertion C5-6 MODUL – Minimal invasive surgery Institute of Surgical Research „C” Module Advance Basic Medical Skills NON-INVASIVE CARDIOVASCULAR MONITORING It is the first line in monitoring of sick patients
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C1-2 MODUL – Non-invasive monitoring;Invasive hemodinamic monitoring
C3-4 MODUL – Laparotomy, enterotomy,Intestinal suture,Diagnostic peritoneal lavage,Chest tube insertion
C5-6 MODUL – Minimal invasive surgery
Institute of Surgical Research„C” Module
Advance Basic Medical Skills
NON-INVASIVE CARDIOVASCULAR
MONITORING
It is the first line in monitoring of sick patients
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Pulse palpating above carotid artery (in pig ordummy);
Pulse rate estimation;
Can estimate systolic blood pressure if can be palpated carotid pulse - then systolic is at least 60 mmHg;
2. Respiration and ventilationMechanical ventillation is need if:
• The spontaneous respiration is insufficient;• It is not spontaneous respiration (apnoe);• In case of hypoxaemia or hypercapnia;
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3. Capnography vs Capnometry
Capnography•Measurement and display of both ETCO2 value and capnogram (CO2 waveform)•Measured by a capnograph
Capnometry•Measurement and display of ETCO2 value (no waveform)•Measured by a capnometer
Continuous non-invasive method for measuring arterial oxygen saturationand pulse rate.
Principle of operation:
infrared absorption by oxygenated and de-oxygenated haemoglobin at twodifferent wavelengths.
4. Pulse oximetry
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The variable absorption due to pulse added volume of arterial blood is used to calculate the saturation of arterial blood
Pulse Oximetry
- Minimizes tissue interference byseparating out the pulsatile signal
- Estimates heart rate by measuring cyclicchanges in light transmission
Oxygen Saturation
Definition:
Percentage of hemoglobin saturated with oxygen
•Normal SpO2 is 95-98%
•Suspect cellular perfusion compromise if < 95% SpO2
•Severe cellular perfusion compromise when SpO2 is < 90%
• SpO2 indicates: the oxygen bound to hemoglobin
• PaO2 indicates the oxygen dissolved in the plasma
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Core temperature = temperature of inner organs (surface -4-5 0C, depends on the site)
Depends on:anatomy - rectum: 37.1± 0.4
oral cavity: 36.7± 0.4axillary: 36.5 ± 0.4
coveringwater contentdaytime (higher in the late afternoon)
5. Temperature monitoring
Electronic device: Termistor (tainted metal oxide semiconductors withnegative temperature coefficients) resistance decreaseswith elevated temperature.
A standard ECG waveform
6. Electrocardiography
It provides information on- Heart rate- Atrial, ventriculal rhythm- Status of myocardial oxygenation- Myocardial diseases- Electrolyte disturbance- Serum K+ level affects the ECG in a predictable and dose related manner- Drug toxicity
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7. Blood pressureIndirect or Direct
Manual or Oscillotonometry (‘electric’)• Mercury manometer• Aneroid manometer
Standard - required machinery– Pulse oxymeter – Apparatus to measure blood pressure, either
directly or non invasively – Electrocardiography – Capnography, when endotracheal tubes or
laryngeal masks are inserted– Apparatus to measure temperature
Monitoring guidelines (ASA)
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7. Gastrointestinal tonometry
Tonomitor includes a semi-permeable siliconeballoon for CO2 at the distal end of the catheter.
Indirect Tonometry: the Basics
Catheter is positioned in the stomach and CO2 freelyequilibrates between the gastric mucosa and the balloon.
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pCO2 HCO3
[ ]
pHi= pKD + lg ————————————
0,03 x
Intramucosalis pH (pHi) determination
From arterial blood sample:HCO3 level is determinated by blood pH and pCO2;
Saline sample from Tonomitor catheter: mucosal pCO2 determination;
Place of puncture: 1. Internal jugular vein; 2. V. subclaviaNormal value of CVP: 2-6 mmHg;
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1. Central vein catheterization
(Surgical Team 1.);
• Surgical exploration of left side jugular vein;
• Percutaneos puncture of jugular vein with asepticSeldinger technique.
• Fix the cannula securely and connect it to the pressure measurement system;
The Seldinger technique for central venous catheterization
1. Introduce a Braunüle into a periferal vein
3. Insert a flexible guide-wire to the central vein
5. Insert – then remove a dilator cannula
6. Insert the central venous cannula
2. Remove the needle
4. Remove the Braunüle cannula
7. Remove of guide-wire
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Axillary (A)Brachial (B)Femoral (F)Radial (R), long catheter
A
B
F
R
2. Measurement of arterial pressure inclinical practice
Arterial pressure transducer
Places of catheterization
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2. Catheterization of femoral artery(Surgical Team 2.)
• Skin incision on the ingvinal area;• Cutting of connective tissue by diatermy;• Abdominal wall is retracted;• Carefull, blunt disection of femoral artery (by
using dressing forceps only);• Catheterization with a termistor sensor supplied
Swan-Ganz catheter; • Fix the catheter securely and connect it to the
pressure sensor;
Monitor
Arterial thermodilution catheter
Injectate temperature sensor
Disposable pressure transducer
Central venous catheter Injectate temperaturesensor housing
3. Cardiac output measurement with a transpulmonary thermodilution method
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Cold salinebolusinjection
Termistorcatheterin aorta
Left HeartRight heart
RA PBVEVLW
LA LV
EVLW
RV
Scheme of transpulmonary thermodilutionmethod
A known volume of cold (2,5-5-10-20 ml; at least 10°C lower than blood temperature) solution is injected intravenously, as fast as possible.
The effect of thermal bolus injected into the central vein is registered by a thermistor catheter positioned in the femoral artery.
The temperature change recorded downstream is dependent on the flow and on the volume through which the cold indicator has passed. As a result, a thermodilution curve can be obtained.
The cardiac output is calculated from the area ofthermodilution curve.
Measurement of Cardiac Output (CO)
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Calculated hemodynamicparameters from arterial
pressure and cardiac output:
Cardiac index = CO/body area (ml/min/m2)
Stroke volume = CO/heart rate (ml)
Peripheral vascular resistance =
= (Mean arterial pressure-CVP)/CO
Goal: to determine the blood gas state of the patient
• O2 uptake
• CO2 excretion in the lung• blood pH• HCO3
- the role of kidneysSteps:
Sample taken;Measurement by blood gas analyser;Data interpreting;
4. Arterial and venous blood sampletaken and blood gas analysis
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1. Sack about 4-times of catheter volum blood beforesample taking (this vill be discarded) by a 5 ml syringe;
2.Fill with heparine (inhibition of blood coagulation) the conus of a 2 ml syringe; (heparine content: 50-100 U/ml blood)!
3.Sack about 1 ml blood into the heparine filledsyringe;
4.Remove air bubble from the syringe;
5.Closed the syringe with cap;
6.Rinse about 5 ml saline the catheter;
Blood sample taken
AVL Compact 2(AVL Medical Instruments)
Sample detecting system:• sense an air bubble;• sense the quantity of sample;
Minimal samle volume: 55 µl
Measurement time: 20 sec
Measurement by blood gas analyser
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Measured parameters:pO2, pCO2, pH
Calculated parametersBE, HCO3
-, O2sat, ctO2,
Metabolits:cLactate, cGlucose
Electrolits:cK+, cNa+, cCl-, cCa2+
Blood gas and Acid-Base parameters:
a negative number is a base deficitmmol/l-2, 0, +2base excess
the [HCO3-] after the
sample has beenequilibrated with CO2 at40mmHg (5,3kPa)
mmol/l22 - 24 - 26standard bicarbonate
normal values vary if thePCO2 is abnormalmmol/l22 - 24 - 26HCO3 (actual
bicarbonate)
lower at high altitude, higher if supplementaloxygen
mmHg90 - 100
at sea level, FiO2 = 21%kPa11.9 - 13.2
pO2
mmHg36 - 40 - 44kPa4.8 - 5.3 - 5.9
pCO2
(no units)7.35 - 7.4 - 7.45pHNotesUnitsNormal rangeItem
Blood Gas Normal Values
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Calculated parameters of oxygentransport and uptake by cardiac
1. Explore the right side jugular vein (Surgical team 1.);
2. Catheterisation with Swan-Ganz catheter;
3. Introduce Swan-Ganz catheter into the arteria pulmonalisby right of monitoring of continous blood pressure signaland helping of the inflatable baloon at the tip of catheter;
4. Pulmonary artery pressure, pulmonary capillar wedgepressure and cardiac output can be measuredsimultenaously;
Introduce a Swan-Ganz catheter into the arteria pulmonalisfrom the jugular vein and through the right heart:
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Transonic animal research flowmeter consists of a bench-top electronic flow detection unit with enhanced frequency resolution and volume flow sensing probes.
The ultrasonic transducer within the flow sensor body transmits a minimum level of ultrasound through a rectangular sensing window and sense volume flow of all liquid passing through this window.
6. Blood flow measurementon carotis artery
.
Acid-base Balance – the Basics
Among the buffer system of the human body bicarbonateregulates the pH of the whole system, because it acts on twopoints:
HCO3- through kidneys
CO2 through the lungs: H+ + HCO3- <=> H2CO3 <=> H2O + O2
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PaCO2 – Partial pressure of CO2 in the arterial blood.PaO2 – Partial pressure of O2 in the arterial blood.Oxygen is carried in the blood in 2 forms:Dissolved O2 (~2-3% of total O2 content)O2 bound to hemoglobin (~97-98% of total O2 content)Total O2 content of blood (Ca O2) = Dissolved O2 + O2
bound to hemoglobinBackground•Oxygen is exchanged by diffusion from higher concentrations to lower concentrations•Most of the oxygen in the arterial blood is carried bound to hemoglobin:
–97% of total oxygen is normally bound to hemoglobin–3% of total oxygen is dissolved in the plasma