8/14/2019 8-Monitoring During Anesthesia
1/108
1
MonitoringMonitoring
duringduring AnesthesiaAnesthesia
8/14/2019 8-Monitoring During Anesthesia
2/108
2
Perioperative periodPerioperative period
operationoperation postoperationpostoperationpreoperationpreoperation
operative evaluationoperative evaluation
and preparationand preparation anesthesiaanesthesia
Induction ofInduction of
anesthesiaanesthesia
Maintenance ofMaintenance of
anesthesiaanesthesia
Recovery fromRecovery from
anesthesiaanesthesia
Monitoring during anesthesiaMonitoring during anesthesia
8/14/2019 8-Monitoring During Anesthesia
3/108
3
The word monitor is derived from the LatinThe word monitor is derived from the Latin
verbverb moneremonere to warn. The purpose of a to warn. The purpose of amonitoring device is to measure amonitoring device is to measure aphysiological variable and to indicatephysiological variable and to indicatetrends of change, thus enablingtrends of change, thus enabling
appropriate therapeutic action to be taken.appropriate therapeutic action to be taken. It is essential to ensure that all monitoringIt is essential to ensure that all monitoring
equipment is maintained correctly andequipment is maintained correctly andthat it functions accurately, so that thethat it functions accurately, so that the
information which it provides is reliableinformation which it provides is reliable The user should understand the basicThe user should understand the basic
principles on which monitoring equipmentprinciples on which monitoring equipmentis based and be able to interpret theis based and be able to interpret the
information provided.information provided.
8/14/2019 8-Monitoring During Anesthesia
4/108
4
MonitoringMonitoring duringduring
AnesthesiaAnesthesia Cardiovascular SystemCardiovascular System
Respiratory systemRespiratory system
Body Temperature: geriatric, pediatricBody Temperature: geriatric, pediatric
Neuromuscular Junction: muscularNeuromuscular Junction: muscular
relaxantrelaxant
Nervous System: depth of anesthesiaNervous System: depth of anesthesia
Coagulation System: cardiothoracicCoagulation System: cardiothoracic
surgerysurgery
8/14/2019 8-Monitoring During Anesthesia
5/108
5
PARTPART
THE CARDIOVASCULARTHE CARDIOVASCULAR
SYSTEMSYSTEM
8/14/2019 8-Monitoring During Anesthesia
6/108
8/14/2019 8-Monitoring During Anesthesia
7/108
7
Electrocardiogram (EElectrocardiogram (ECCG)G)
ECG monitors have become increasinglyECG monitors have become increasingly
reliable and less subject to interference.reliable and less subject to interference.
As the technique is non-invasive, simpleAs the technique is non-invasive, simple
and accurate, it is now regarded asand accurate, it is now regarded as
mandatory in the UK that the ECG shouldmandatory in the UK that the ECG should
be monitored in all patients undergoingbe monitored in all patients undergoinganaesthesia, no matter how minor theanaesthesia, no matter how minor the
surgery procedure.surgery procedure.
8/14/2019 8-Monitoring During Anesthesia
8/108
8
Electrocardiogram (EElectrocardiogram (ECCG)G)
One of the standardized monitors duringOne of the standardized monitors during
any form of anesthesia.any form of anesthesia.
For detection and diagnosis ofFor detection and diagnosis of
DysrhythmiasDysrhythmias: Tachycardia, Bradycardia,: Tachycardia, Bradycardia,VFVF
CConduction defectsonduction defects: AVB: AVB auriculo-ventricular blockCCardiac ischemiaardiac ischemia: CAD: CAD
EElectrolyte disturbancelectrolyte disturbance: Potassium,: Potassium,
MagnesiumMagnesiumhyperkalemia, hypokalemia
8/14/2019 8-Monitoring During Anesthesia
9/108
9
Types of MonitoringTypes of Monitoring
Five-electrode system: one onFive-electrode system: one on
each leach limbimb and one precordial leadand one precordial lead
(V(V5,5, along the anterior axillary linealong the anterior axillary line
in the fifth intercostal spacein the fifth intercostal space forfor
detection of anterior ischemia).detection of anterior ischemia).
8/14/2019 8-Monitoring During Anesthesia
10/108
10
PPrecordial leadrecordial lead
Midclavicular line
Anterior axillary line Midaxillary line
Posterior axillary line
8/14/2019 8-Monitoring During Anesthesia
11/108
11
Standard limb lead
8/14/2019 8-Monitoring During Anesthesia
12/108
12
Types of MonitoringTypes of Monitoring
Standard lead II monitoring is usedStandard lead II monitoring is used
widely.widely.
However, the CMHowever, the CM55 lead configuration haslead configuration has
been advocated for routine intraoperativebeen advocated for routine intraoperative
monitoring because it reveals moremonitoring because it reveals more
readily ST segment changes produced byreadily ST segment changes produced by
left ventricular ischaemia.left ventricular ischaemia.
8/14/2019 8-Monitoring During Anesthesia
13/108
13
Types of MonitoringTypes of Monitoring
8/14/2019 8-Monitoring During Anesthesia
14/108
14
Types of MonitoringTypes of Monitoring
Right arm lead overmanubrium sterni
8/14/2019 8-Monitoring During Anesthesia
15/108
15
Electrocardiogram (EElectrocardiogram (ECCG)G)
KaplanKaplan et al.et al. (Anesthesiology, 1976):(Anesthesiology, 1976):
90% of intraoperative cardiac ischemia will90% of intraoperative cardiac ischemia will
be detected by multiple Ebe detected by multiple ECCG, especially VG, especially V55..
At least two leads should be simultaneouslyAt least two leads should be simultaneously
showed on the monitor.showed on the monitor.
8/14/2019 8-Monitoring During Anesthesia
16/108
16
Position of the LeadsPosition of the Leads
The four limb leads should be placed onThe four limb leads should be placed on
the back of shoulders and hips, wherethe back of shoulders and hips, where
they will disturb the operative field thethey will disturb the operative field theleast.least.
Every lead should be fixed and protectedEvery lead should be fixed and protected
with tape to prevent dislodgement ofwith tape to prevent dislodgement ofleads during operation.leads during operation.
8/14/2019 8-Monitoring During Anesthesia
17/108
17
Electrocardiogram (EElectrocardiogram (ECCG)G)
It is important to appreciate that the ECGIt is important to appreciate that the ECG
is an index only of electrical activity. It isis an index only of electrical activity. It is
possible for a normal electrical waveformpossible for a normal electrical waveformto exist in the presence of a negligibleto exist in the presence of a negligible
cardiac output.cardiac output.
Consequently, information from the ECGConsequently, information from the ECGshould be used in conjunction with datashould be used in conjunction with data
acquired from monitoring of perfusionacquired from monitoring of perfusion
8/14/2019 8-Monitoring During Anesthesia
18/108
18
Monitoring the circulationMonitoring the circulation Maintenance of perfusion of vital organs is oneMaintenance of perfusion of vital organs is one
of the principal tasks of the anaesthetist duringof the principal tasks of the anaesthetist during
surgery. Adequate perfusion is dependent onsurgery. Adequate perfusion is dependent on
adequate venous return to the heart, cardiacadequate venous return to the heart, cardiac
performance and arterial pressure.performance and arterial pressure. Direct measurements of cardiac output andDirect measurements of cardiac output and
blood volume are difficult during anaesthesiablood volume are difficult during anaesthesia
and require invasive procedures which areand require invasive procedures which are
inappropriate in many situations.inappropriate in many situations.
8/14/2019 8-Monitoring During Anesthesia
19/108
19
Monitoring the circulationMonitoring the circulation However, adequacy of cardiac output andHowever, adequacy of cardiac output and
circulating blood volume may be inferredcirculating blood volume may be inferred
indirectly from observation of the followingindirectly from observation of the following
variables:variables:
1. Peripheral pulse.1. Peripheral pulse.
2. Arterial oxygen saturation.2. Arterial oxygen saturation.
3. Peripheral perfusion.3. Peripheral perfusion.
4. Urine production.4. Urine production.
5.Arterial pressure.5.Arterial pressure.
8/14/2019 8-Monitoring During Anesthesia
20/108
20
1.Regular palpation of the peripheralpulse is one of the simplest and most
useful methods of monitoring during
anaesthesia and is mandatory for even
the most minor surgery. (Radial artery)
2.Information may be obtained by
observation of the rate, volume and
rhythm.
The peripheral pulseThe peripheral pulse
8/14/2019 8-Monitoring During Anesthesia
21/108
21
1.Pulse oximeters measure the arterial
oxygen saturation and the pulse rate
non-invasively and accurately to within
2%.
2.A simple probe is attached to a finger
an ear lobe, flexed across the nasalbridge, or wrapped around a childs digit
and connected to the oximeter.
3.The probe contains two light-emittingdiodes, one for red and one for infrared
light, and a single detector positioned
on the opposite side of the digit or ear
lobe.
Pulse oximetryPulse oximetry
8/14/2019 8-Monitoring During Anesthesia
22/108
22
Pulse oximetry----ProbePulse oximetry----Probe
Finger probe forpulse oximeterattached to afinger
8/14/2019 8-Monitoring During Anesthesia
23/108
23
Pulse oximetry----Pulse oximetry----
ProbeProbe
Disposable fingerprobe for pulseoximeterwrapped around a
childs digit
8/14/2019 8-Monitoring During Anesthesia
24/108
24
Pulse oximetry----Pulse oximetry----
OximeterOximeter
Pulseoximeter
control anddisplaymodule,probe is
connected to
Waveform S
pO2
Pulse rate
8/14/2019 8-Monitoring During Anesthesia
25/108
25
Pulse oximetryPulse oximetry
Pathophysiology:
Oxygen is exchanged by diffusion fromOxygen is exchanged by diffusion from
higher concentrations to lowerhigher concentrations to lower
concentrationsconcentrations
Most of the oxygen in the arterial blood isMost of the oxygen in the arterial blood is
carried bound to hemoglobincarried bound to hemoglobin
-97% of total oxygen is normally bound to-97% of total oxygen is normally bound tohemoglobin (hemoglobin (SpOSpO22))
-3% of total oxygen is dissolved in the-3% of total oxygen is dissolved in the
plasma (Paplasma (PaOO22))
8/14/2019 8-Monitoring During Anesthesia
26/108
26
Pulse oximetryPulse oximetry
Oxygen Saturation: Percentage of hemoglobin saturated withPercentage of hemoglobin saturated with
oxygenoxygen
Normal SpONormal SpO
22 is 95-98%is 95-98%
Suspect cellular perfusion compromise ifSuspect cellular perfusion compromise if
SpOSpO22 is less than 95%is less than 95%
-Insure adequate airway-Insure adequate airway
-Provide supplemental oxygen-Provide supplemental oxygen
-Monitor carefully for further changes and-Monitor carefully for further changes and
intervene appropriatelyintervene appropriately
8/14/2019 8-Monitoring During Anesthesia
27/108
27
Pulse oximetryPulse oximetry
Oxygen Saturation:
Suspect severe cellular perfusionSuspect severe cellular perfusion
compromise when SpOcompromise when SpO22 is less than 90%is less than 90% Insure airway and provide positiveInsure airway and provide positive
ventilations if necessary.ventilations if necessary.
Administer high flow oxygen.Administer high flow oxygen. Head injured patients, SpOHead injured patients, SpO22shouldshould
never drop below 90%.never drop below 90%.
8/14/2019 8-Monitoring During Anesthesia
28/108
28
Pulse oximetryPulse oximetry
SpO2 and PaO2:
SpOSpO22 indicates the oxygen bound toindicates the oxygen bound to
hemoglobinhemoglobin-Closely corresponds to SaO-Closely corresponds to SaO22 measured inmeasured in
laboratory testslaboratory tests
-SpO-SpO22 indicates the saturation wasindicates the saturation was
obtained with non-invasive oximetryobtained with non-invasive oximetry
PaOPaO22 indicates the oxygen dissolved in theindicates the oxygen dissolved in the
plasmaplasma
-Measured in ABGs (artery blood gases)-Measured in ABGs (artery blood gases)
8/14/2019 8-Monitoring During Anesthesia
29/108
29
Pulse oximetryPulse oximetry
SpO2 and PaO2:
Normal PaONormal PaO22 is 80-100 mmHgis 80-100 mmHg
NormallyNormally
80-100 mm Hg corresponds to 95-100%80-100 mm Hg corresponds to 95-100%
SpOSpO22
60 mm Hg corresponds to 90% SpO60 mm Hg corresponds to 90% SpO22
40 mm Hg corresponds to 75% SpO40 mm Hg corresponds to 75% SpO22
8/14/2019 8-Monitoring During Anesthesia
30/108
30
1.Pulse oximeters are simple to use, non-
invasive and require no warm-up time.
2.Provide an overall assessment of the
integrity of all the systems involved in
delivering oxygen to the tissues
Oxygen supply, intake and delivery.
3.unaffected by pigmented skin
Pulse oximetryPulse oximetry
Advantages:
8/14/2019 8-Monitoring During Anesthesia
31/108
8/14/2019 8-Monitoring During Anesthesia
32/108
32
1.It is assessed most usefully by
observation of the patient's extremities.
2.Warm, dry, pink skin indicates adequate
peripheral perfusion; cold, white
peripheries the converse
3.This is particularly true in children, inwhom cool peripheries usually indicate
hypovolaemia.
Peripheral perfusionPeripheral perfusion
8/14/2019 8-Monitoring During Anesthesia
33/108
33
1.The core-peripheral temperature
gradient is a useful index of adequacy
of peripheral perfusion.
2.One temperature probe is placed
centrally (e.g. in the nasopharynx) and
the other peripherally (e.g. on the greattoe)
3.The temperature gradient increases
with vasoconstriction and low cardiacoutput, and decreases gradually as
vasodilation occurs with increasing limb
blood flow consequent upon increasing
cardiac output.
Peripheral perfusionPeripheral perfusion
8/14/2019 8-Monitoring During Anesthesia
34/108
34
1.Adequacy of renal perfusion may be
inferred from the volume of urine
produced
2.The kidney is the only organ whose
function may be monitored directly in
this way.
3.Adequate production of urine implies
that perfusion of other vital organs is
Urine outputUrine output
8/14/2019 8-Monitoring During Anesthesia
35/108
35
1.Accurate measurement of urine
volumes with a urimeter is particularly
indicated in the following situations:
Urine outputUrine output
6. Surgery in the jaundiced
patient.
3. Major trauma.
5. Massive fluid or blood
loss
2. Cardiac surgery.
4. Critically ill/shocked
patients
1. Major vascular
surgery.
aim is to achieve a urine output of 0.5~1ml.kg-1.h-1
8/14/2019 8-Monitoring During Anesthesia
36/108
3 It is an indirect method of estimating
8/14/2019 8-Monitoring During Anesthesia
37/108
37
3. It is an indirect method of estimating
adequacy of
cardiac output, because:
Blood pressure CO peripheral
resistance
4. In conjunction with estimation ofperipheral
perfusion, it is an invaluable
measurement.
6. Indirect, non-invasive methods of
measurement
Systemic arterialSystemic arterial
pressurepressure
8/14/2019 8-Monitoring During Anesthesia
38/108
38
Palpation of the radial pulse as the
sphygmoma-nometer cuff is deflated is
a simple method of measuring systolic
pressure, but is inaccurate at low
pressures or when vasoconstriction is
present.
Systemic arterialSystemic arterial
pressurepressurePalpation :
8/14/2019 8-Monitoring During Anesthesia
39/108
39
1.Auscultation of the Korotkoff sounds is
too cumbersome for routine use during
anaesthesia.
Systemic arterialSystemic arterial
pressurepressureAuscultation :
8/14/2019 8-Monitoring During Anesthesia
40/108
8/14/2019 8-Monitoring During Anesthesia
41/108
41
Systemic arterialSystemic arterial
pressurepressureOscillometry (2):
an automated oscillometer
8/14/2019 8-Monitoring During Anesthesia
42/108
42
Systemic arterialSystemic arterial
pressurepressureOscillometry (2):
Multifunctional Monitor
8/14/2019 8-Monitoring During Anesthesia
43/108
8/14/2019 8-Monitoring During Anesthesia
44/108
44
Cuff SizeCuff Size
Too small cuff will result in highToo small cuff will result in high
blood pressure reading.blood pressure reading. A loosely applied cuff will alsoA loosely applied cuff will also
produce a reading higher than itproduce a reading higher than it
should be.should be.
Too large cuff will severelyToo large cuff will severely
8/14/2019 8-Monitoring During Anesthesia
45/108
45
Cuff SizeCuff Size
from Barbara Bates: A Guide to Physical
Examination
8/14/2019 8-Monitoring During Anesthesia
46/108
46
Systemic arterialSystemic arterial
pressurepressureOscillometry (3):
a.Inaccurate when SBP less than 60mmHg
.
b. Unable to follow rapid swings in arterial
pressure .
c. Under-reading occurred at high systolic
pressures
Disadvantages:
8/14/2019 8-Monitoring During Anesthesia
47/108
47
1. It is achieved by attaching a
transducer to an intra-arterial cannula
inserted into a peripheral artery.
2. It is an invasive procedure which
carries potential morbidity.
3. The method is only justified whenrapid changes in arterial pressure are
anticipated during anaesthesia.
Direct measurement ofDirect measurement of
ABPABP
8/14/2019 8-Monitoring During Anesthesia
48/108
48
IABP system
CannulaManometertubeTransducerMonitor
8/14/2019 8-Monitoring During Anesthesia
49/108
49
1. The transducer should be zeroed, and
the system should be calibrated.
2. The transducer is connected to the
cannula via a piece of stiff-walled,saline-filled manometer tube.
3. The pressure signal is displayed as a
waveform on an oscilloscope screen and
systolic, diastolic and mean arterial
pressures displayed digitally.
Direct measurement ofDirect measurement of
ABPABP
8/14/2019 8-Monitoring During Anesthesia
50/108
50
Common indications for arterialcannulation:
Direct measurement ofDirect measurement of
ABPABP
Major vascular surgery
Cardiothoracic surgery
Induced hypotension
Critically ill and shocked patients
Surgery for pheochromocytoma
Neurosurgery
Necessity for frequent blood gas analysis
8/14/2019 8-Monitoring During Anesthesia
51/108
51
Morbidity associated with arterialcannulation :
Direct measurement ofDirect measurement of
ABPABP
1. Arterial wall damage and
thrombosis
2. Embolization
3. Disconnection and
haemorrhage4. Sepsis
5. Tissue necrosis
8/14/2019 8-Monitoring During Anesthesia
52/108
52
Direct measurement ofDirect measurement of
ABPABP
Site for Arterial Cannulation:
1. Radial artery:
2. Femoral artery:
3. Brachial artery:
4. Dorsalis pedis artery:
8/14/2019 8-Monitoring During Anesthesia
53/108
53
1. A central venous catheter positioned
with its tip in the superior (inferior) vena
cava.
2. It provides valuable information
concerning the volume status of thecirculation during anaesthesia.
3. A direct measurement of RV filling
pressure, CVP is good measurement of
LV filling pressure only in the absence of
pulmonary hypertension or mitral
Central venousCentral venous
pressure (CVP)pressure (CVP)
8/14/2019 8-Monitoring During Anesthesia
54/108
54
Central venousCentral venous
pressure (CVP)pressure (CVP)
tip in the superior
Internal jugular
vein
External jugular
vein
8/14/2019 8-Monitoring During Anesthesia
55/108
55
Central venousCentral venous
pressure (CVP)pressure (CVP)
Femoral Vein
8/14/2019 8-Monitoring During Anesthesia
56/108
56
Central venousCentral venous
pressurepressure
Site for Vein Cannulation:
1. Internal jugular vein
2. External jugular vein3. Subclavian vein
4. Femoral vein
5.Peripheral arm vein
8/14/2019 8-Monitoring During Anesthesia
57/108
57
Peripheral arm vein :
Central venousCentral venous
pressurepressure1.This route is the least likely to provide
correct placement of the catheter
(approximately 40%)
2.It avoids most of the serious
complications of other routes of
insertion.
3.Thrombophlebitis and sepsis are
common when a peripheral arm vein is
used, particularly if the catheter is left
8/14/2019 8-Monitoring During Anesthesia
58/108
58
Internal jugular cannulation:
Central venousCentral venous
pressurepressure
This route is associated with the
highest incidence of correct
catheter placement (approximately
90%).
8/14/2019 8-Monitoring During Anesthesia
59/108
59
Technique for right internal jugularTechnique for right internal jugular
vein central venous cannulation.vein central venous cannulation.
P t
8/14/2019 8-Monitoring During Anesthesia
60/108
60
(A) Important surface landmarks are identified.(A) Important surface landmarks are identified.
(B) The course of the internal carotid artery is palpated.(B) The course of the internal carotid artery is palpated. (C) The internal jugular vein is punctured at the apex of(C) The internal jugular vein is punctured at the apex of
the triangle formed by the two heads of thethe triangle formed by the two heads of thesternocleidomastoid muscle with the needle tip directedsternocleidomastoid muscle with the needle tip directedtoward the ipsilateral nipple.toward the ipsilateral nipple.
(D) A guide wire is introduced through the thin-wall(D) A guide wire is introduced through the thin-wallneedle into the vein.needle into the vein.
(E) The central venous cannula is inserted over the(E) The central venous cannula is inserted over theguide wire, making sure that the proximal end of theguide wire, making sure that the proximal end of theguide wire protrudes beyond the catheter and isguide wire protrudes beyond the catheter and is
controlled by the operator. See text for greater detail.controlled by the operator. See text for greater detail.
PunctureProcedure
C l
8/14/2019 8-Monitoring During Anesthesia
61/108
61
Complications of internal jugularcannulation:
Central venousCentral venous
pressurepressure
1. Air embolism
2. Carotid artery puncture
3. Brachial plexus/phrenic nerve
damage
4. Ectopic placement (numerous
sites)5. Sepsis
6. Pneumothorax
lC t l
8/14/2019 8-Monitoring During Anesthesia
62/108
62
Subclavian vein:
Central venousCentral venous
pressurepressure
1.This approach is more hazardous
than the internal jugular, and less
likely to provide correct catheter
placement.
2.It is the most suitable route if long-
term parenteral feeding.
C lC t l
8/14/2019 8-Monitoring During Anesthesia
63/108
63
Complications of subclavian veincannulation :
Central venousCentral venous
pressurepressure
1. Pneumothorax
2. Subclavian artery puncture
3. Air embolism
4. Damage to thoracic duct (left
side)
8/14/2019 8-Monitoring During Anesthesia
64/108
64
Measurement should be done atMeasurement should be done at end-end-
expirationexpiration phase.phase.
8/14/2019 8-Monitoring During Anesthesia
65/108
65
Right atriumCVP
8/14/2019 8-Monitoring During Anesthesia
66/108
C t lC t l
8/14/2019 8-Monitoring During Anesthesia
67/108
67
Measurement of CVP:
Central venousCentral venous
pressurepressure1.The normal range of values is
0~6cmH2O in the spontaneously
breathing patient.
2.In patients receiving IPPV values of
CVP are approximately 5 cmH2O higher
because of the increased mean
intrathoracic pressure
3.Trends in measured observations are
C t lC t l
8/14/2019 8-Monitoring During Anesthesia
68/108
68
Increase of CVP :
Central venousCentral venous
pressurepressure
1. Over hydration
2. Right-sided heart failure3. Cardiac tamponade
4. Constrictive pericarditis
5. Pulmonary hypertension6. Tricuspid stenosis and regurgitation
7. stroke volume is high
Pulmonary artery pressurePulmonary artery pressure
8/14/2019 8-Monitoring During Anesthesia
69/108
69
Pulmonary artery pressurePulmonary artery pressure
monitoringmonitoring
It can measure:It can measure:
2.2. PA pressurePA pressure
3.3. Pulmonary capillary wedged pressurePulmonary capillary wedged pressure(PCWP): a balloon at catheter tip(PCWP): a balloon at catheter tip
(volume 1.5 ml), when the balloon is(volume 1.5 ml), when the balloon is
inflated and the vessel is wedged, ainflated and the vessel is wedged, a
valveless hydrostatic column existsvalveless hydrostatic column existsbetween the distal port and LA.between the distal port and LA.
PAPPAC (Swan-PAPPAC (Swan-Ganz)Ganz)
Pulmonary artery pressurePulmonary artery pressure
8/14/2019 8-Monitoring During Anesthesia
70/108
70
Pulmonary artery pressurePulmonary artery pressure
monitoringmonitoring
1.1. CVP: a port for CVP measurement isCVP: a port for CVP measurement is
located at 30 cm from the tiplocated at 30 cm from the tip
2.2. Cardiac output: measurement of RVCardiac output: measurement of RV
outputoutput
3.3. Blood temperatureBlood temperature
4.4. Derived hemodynamic dataDerived hemodynamic data
n Mixed Venous OMixed Venous O22 saturation (SvOsaturation (SvO22))
The Pulmonary ArteryThe Pulmonary Artery
8/14/2019 8-Monitoring During Anesthesia
71/108
71
The Pulmonary Arteryy y
CatheterCatheter
(PA catheter, Swan-Ganz)(PA catheter, Swan-Ganz)
PAP, PCWP, SvO2
CVP
Blood temperature CO
Administration
8/14/2019 8-Monitoring During Anesthesia
72/108
72
Pulmonary Artery CatheterPulmonary Artery Catheter1. The proximal lumen. This is situatedapproximately 25 cm from the tip and should lie in
the right atrium after final placement of the catheter.
CVP may be measured using this lumen.
2. The distal lumen Situated at the tip of thecatheter, this lumen lies in a major branch of the
pulmonary artery when the catheter is placed
correctly and is used to measure pulmonary artery
pressure by connecting it to a suitable transducer.
3. The balloon lumen. This lumen permits the
introduction of approximately 1.5 ml of air into the
ballon which surrounds the distal tip of the lumen.
4. Thermistor lumen. A bead thermistor is
situated 4cm from the tip of the catheter and
measures the tem erature of blood at this site.
P l A tPulmonary Artery
8/14/2019 8-Monitoring During Anesthesia
73/108
73
Pulmonary ArteryPulmonary Artery
CatheterCatheter
PA Port:PA Port:YELLOWYELLOW
CVP Port:CVP Port:BLUEBLUE
PA balloon Port:PA balloon Port:REDRED
1 Distal port opening is at1 Distal port opening is at
8/14/2019 8-Monitoring During Anesthesia
74/108
74
1. Distal port opening is at1. Distal port opening is at
the tip (end) of thethe tip (end) of the
cathetercatheter.. pulmonary artery pressures (PAP)pulmonary artery pressures (PAP) systolic (PAS)systolic (PAS)
diastolic (PAD)diastolic (PAD) pulmonary capillary wedge pressure (PCWP)pulmonary capillary wedge pressure (PCWP)
when balloon is inflated PA pressures shouldwhen balloon is inflated PA pressures shouldalways be monitored continuouslyalways be monitored continuously
NEVER USENEVER USE for medication infusionfor medication infusion Can be used for drawing "mixed venous" bloodCan be used for drawing "mixed venous" blood
gas samplegas sample
8/14/2019 8-Monitoring During Anesthesia
75/108
75
2.2.Balloon portBalloon port
located about < 1 cm from tip of the catheterlocated about < 1 cm from tip of the catheter
the balloon is inflated with proximately 0.8 to 1.5 ccthe balloon is inflated with proximately 0.8 to 1.5 cc
of airof air do not inflate with liquid---- always inflate with airdo not inflate with liquid---- always inflate with air
when deflated, turn stopcock to off position andwhen deflated, turn stopcock to off position and
leave syringe connect to portleave syringe connect to port
3 Th i t d3 Th i t d
8/14/2019 8-Monitoring During Anesthesia
76/108
76
3. Thermistor and3. Thermistor and
connector portconnector port the thermistor connector connects thethe thermistor connector connects thepulmonary catheter to the cardiac outputpulmonary catheter to the cardiac outputcomputercomputer
thermistor wire within the lumen transmitsthermistor wire within the lumen transmitsblood temperature (core temperature is mostblood temperature (core temperature is mostaccurate reflection of the body temperature)accurate reflection of the body temperature)used in determiningused in determining cardiac outputcardiac output
i l4 P i l t
8/14/2019 8-Monitoring During Anesthesia
77/108
77
4.Proximal port 4.Proximal port
approximately 30 cm fromapproximately 30 cm fromtip of catheter.tip of catheter. also known as CVP port (central venousalso known as CVP port (central venous
pressure) lies in the right atrium andpressure) lies in the right atrium and
measures CVP can be used for infusion of IVmeasures CVP can be used for infusion of IV
solutions or medicationssolutions or medications
8/14/2019 8-Monitoring During Anesthesia
78/108
78
8/14/2019 8-Monitoring During Anesthesia
79/108
79
i f h hL i f h h
8/14/2019 8-Monitoring During Anesthesia
80/108
80
Location of the catheterLocation of the catheter
8/14/2019 8-Monitoring During Anesthesia
81/108
8/14/2019 8-Monitoring During Anesthesia
82/108
82
W f d i I i
8/14/2019 8-Monitoring During Anesthesia
83/108
83
Waveform during InsertionWaveform during Insertion
8/14/2019 8-Monitoring During Anesthesia
84/108
84
Length of InsertionLength of Insertion
Usual conditions (just for ease toUsual conditions (just for ease to
memorize)memorize)
35 cm: RV35 cm: RV 4545 cm: PAcm: PA
55 cm: wedge55 cm: wedge
But the actual length may varyBut the actual length may vary
greatly between patients!greatly between patients!
HemodynamicHemodynamic
8/14/2019 8-Monitoring During Anesthesia
85/108
85
yMeasurements--Measurements--NormalNormal
RangeRange RA pressure: 2~6 mmHgRA pressure: 2~6 mmHg
RV pressure:RV pressure: systolic 15~25 mmHg;systolic 15~25 mmHg;
diastolic 0~4 mmHgdiastolic 0~4 mmHg PA pressure: systolic 15~25 mmHg;PA pressure: systolic 15~25 mmHg;
diastolic 8~16 mmHgdiastolic 8~16 mmHg
Mean PAP: 10~20 mmHgMean PAP: 10~20 mmHg
Pulmonary Capillary Wedge PressurePulmonary Capillary Wedge Pressure
(PCWP): 6~12 mmHg(PCWP): 6~12 mmHg
Derived HemodynamicDerived Hemodynamic
8/14/2019 8-Monitoring During Anesthesia
86/108
86
Derived HemodynamicDerived Hemodynamic
ProfilesProfiles
Systemic Vascular ResistanceSystemic Vascular Resistance
(SVR): 80 x (MAP-CVP)/CO;(SVR): 80 x (MAP-CVP)/CO;
800~1200 dyne-sec-cm800~1200 dyne-sec-cm-5-5
Pulmonary Vascular ResistancePulmonary Vascular Resistance
(PVR): 80 x (PAP-PCWP)/CO;(PVR): 80 x (PAP-PCWP)/CO;20~130 dyne-sec-cm20~130 dyne-sec-cm-5-5
Derived HemodynamicDerived Hemodynamic
8/14/2019 8-Monitoring During Anesthesia
87/108
87
Derived HemodynamicDerived Hemodynamic
ProfilesProfiles
Cardiac Output: thermodilutionCardiac Output: thermodilution
method; 4~8 L/minmethod; 4~8 L/min
Cardiac Index: CO/BSA; 2.5~4.2Cardiac Index: CO/BSA; 2.5~4.2L/min/mL/min/m22
Continuous CardiacContinuous Cardiac
8/14/2019 8-Monitoring During Anesthesia
88/108
88
Continuous CardiacContinuous Cardiac
OutputOutput
Continuous Cardiac Output (CCO)Continuous Cardiac Output (CCO)
measurement can be achieved bymeasurement can be achieved by
a electric coil attached on the tipa electric coil attached on the tipof PA catheter. It automaticallyof PA catheter. It automatically
measures CO every 3 min.measures CO every 3 min.
Mixed Venous OxygenMixed Venous Oxygen
8/14/2019 8-Monitoring During Anesthesia
89/108
89
Mixed Venous OxygenMixed Venous Oxygen
Saturation (SvOSaturation (SvO22))
Mixed by blood from both SVCMixed by blood from both SVC
and IVC, sampled at PAand IVC, sampled at PA
OO22 consumption= SaOconsumption= SaO22-SvO-SvO22SvOSvO22=SaO=SaO22 - (VO- (VO22/Q x Hb x 13)/Q x Hb x 13)
8/14/2019 8-Monitoring During Anesthesia
90/108
8/14/2019 8-Monitoring During Anesthesia
91/108
Clinical monitoring ofClinical monitoring of
8/14/2019 8-Monitoring During Anesthesia
92/108
92
Clinical monitoring ofClinical monitoring of
ventilationventilation
Continuous observation should beContinuous observation should bemade of the following :made of the following :
1. patient's colour .1. patient's colour .
2. respiratory rate .2. respiratory rate .3. adequacy of chest movement .3. adequacy of chest movement .
4. movement of the reservoir bag or4. movement of the reservoir bag or
ventilator bellows .ventilator bellows .
Clinical monitoring ofClinical monitoring of
8/14/2019 8-Monitoring During Anesthesia
93/108
93
Clinical monitoring ofClinical monitoring of
ventilationventilation Auscultation of both lung fields shouldAuscultation of both lung fields should
also be performed frequently in orderalso be performed frequently in order
to detect :to detect :
1. equality of air entry .1. equality of air entry .
2. intubation of a bronchus .2. intubation of a bronchus .
3. presence of secretions .3. presence of secretions .
4. occurrence of a pneumothorax .4. occurrence of a pneumothorax .
Clinical monitoring ofClinical monitoring of
8/14/2019 8-Monitoring During Anesthesia
94/108
94
Clinical monitoring ofClinical monitoring of
ventilationventilation
Anaesthetist must check regularly for signs ofAnaesthetist must check regularly for signs of
respiratory obstruction as evidenced by:respiratory obstruction as evidenced by:
1. tracheal tug .1. tracheal tug .
2. paradoxical abdominal movement .2. paradoxical abdominal movement .
3. absence of bag deflation .3. absence of bag deflation .
Some ventilators make a regular noise duringSome ventilators make a regular noise during
part of the ventilating cycle and this is apart of the ventilating cycle and this is avaluable audible monitor.valuable audible monitor.
Measurement of airwayMeasurement of airway
8/14/2019 8-Monitoring During Anesthesia
95/108
95
Measurement of airwayMeasurement of airway
pressurepressure
Airway pressure may reflect changes in lung andAirway pressure may reflect changes in lung and
chest wall compliance :chest wall compliance :
Chest wall compliance may be influenced by :Chest wall compliance may be influenced by :
1. degree of muscle paralysis .1. degree of muscle paralysis .
2. surgical manipulation .2. surgical manipulation .
3. position of the patient .3. position of the patient .
Measurement of airwayMeasurement of airway
8/14/2019 8-Monitoring During Anesthesia
96/108
96
Measurement of airwayMeasurement of airway
pressurepressure
Lung compliance may be influenced by :Lung compliance may be influenced by :
1. accumulation of secretions .1. accumulation of secretions .
2. development of a pneumothorax .2. development of a pneumothorax .
3. position of the patient .3. position of the patient .
Increased resistance to air flow caused byIncreased resistance to air flow caused by
bronchospasm or obstruction of the trachealbronchospasm or obstruction of the trachealtube is reflected by an increased peak airwaytube is reflected by an increased peak airway
pressure.pressure.
Measurement of airwayMeasurement of airway
8/14/2019 8-Monitoring During Anesthesia
97/108
97
Measurement of airwayMeasurement of airway
pressurepressure
1.1. Kinking of ventilator tubing or tracheal tube.Kinking of ventilator tubing or tracheal tube.
2.2. Overinflation of the tracheal tube cuff withOverinflation of the tracheal tube cuff with
consequent obstruction of the lumen of the tube.consequent obstruction of the lumen of the tube.3.3. Increased secretions.Increased secretions.
4.4. Pneumothorax.Pneumothorax.
5.5. Bronchospasm.Bronchospasm.
6.6. Inadequate muscle relaxation.Inadequate muscle relaxation.
ses of elevation of airway pressure
8/14/2019 8-Monitoring During Anesthesia
98/108
98
Disconnection alarmDisconnection alarm
When the lungs are ventilated mechanically, theWhen the lungs are ventilated mechanically, the
continuity of the anaesthetic breathing system,continuity of the anaesthetic breathing system,
and thus of gas delivery to the patient, should beand thus of gas delivery to the patient, should be
monitored using a disconnection alarmmonitored using a disconnection alarm The alarm is activated if the airway pressureThe alarm is activated if the airway pressure
decreases below a preset minimum for a presetdecreases below a preset minimum for a preset
time interval.time interval.
8/14/2019 8-Monitoring During Anesthesia
99/108
99
Disconnection alarmDisconnection alarm
A large leak, or total disconnection, is indicated ifA large leak, or total disconnection, is indicated ifthe alarm is triggered.the alarm is triggered.
In addition, most of these devices sound an alarmIn addition, most of these devices sound an alarm
if excessive airway pressures are generated.if excessive airway pressures are generated.
A disconnection alarm does not obviate the needA disconnection alarm does not obviate the need
for visual surveillance of the continuity of thefor visual surveillance of the continuity of the
breathing system.breathing system.
End-tidal carbon dioxideEnd-tidal carbon dioxide
8/14/2019 8-Monitoring During Anesthesia
100/108
100
End tidal carbon dioxideEnd tidal carbon dioxide
tension (PE'cotension (PE'co22)) PE'coPE'co
22
, correlates well with Paco, correlates well with Paco22
, in patients who, in patients who
have no significant pulmonary disease.have no significant pulmonary disease.
Normal PacoNormal Paco22-PE'co-PE'co22 gradient is approximatelygradient is approximately
5mmHg. (Paco5mmHg. (Paco22 35-45mmHg, PE'co35-45mmHg, PE'co22 30-40mmHg.)30-40mmHg.)
End-tidal carbon dioxide concentration may beEnd-tidal carbon dioxide concentration may be
measured using the principle of infrared absorptionmeasured using the principle of infrared absorption
spectrophotometry.spectrophotometry.
PPETETCOCO
22
End-tidal carbon dioxideEnd-tidal carbon dioxide
8/14/2019 8-Monitoring During Anesthesia
101/108
101
End tidal carbon dioxideEnd tidal carbon dioxide
tension (PE'cotension (PE'co22))
PE'coPE'co22 is useful particularly in the followingis useful particularly in the followingcircumstances.circumstances.
b.b. To provide evidence of correct placement of theTo provide evidence of correct placement of the
tracheal tube. Capnography is the only methodtracheal tube. Capnography is the only method
available which provides rapid and reliableavailable which provides rapid and reliablediagnosis of intubation of the oesophagus.diagnosis of intubation of the oesophagus.
c.c. For routine monitoring of the adequacy ofFor routine monitoring of the adequacy of
ventilation and the effects of IPPV.ventilation and the effects of IPPV.
d.d. To detect rebreathing.To detect rebreathing.
PPETETCOCO
22
End-tidal carbon dioxideEnd-tidal carbon dioxide
8/14/2019 8-Monitoring During Anesthesia
102/108
102
End tidal carbon dioxideEnd tidal carbon dioxide
tension (PE'cotension (PE'co22))
To detect air, fat or pulmonary embolism; a suddenTo detect air, fat or pulmonary embolism; a suddendecrease in PE'codecrease in PE'co22 occurs as a result of increasedoccurs as a result of increased
dead spacedead space
n To detect malignant hyperthermia; a progressiveTo detect malignant hyperthermia; a progressive
increase in PE'coincrease in PE'co22, results from increased muscle, results from increased musclemetabolism.metabolism.
n To ensure normocapnia in elderly patients in anTo ensure normocapnia in elderly patients in an
attempt to maintain adequate cerebral perfusion.attempt to maintain adequate cerebral perfusion.
n To maintain normal PE'coTo maintain normal PE'co22 during carotid arteryduring carotid artery
surgery in order to maintain cerebral perfusion.surgery in order to maintain cerebral perfusion.
PPETETCOCO
22
8/14/2019 8-Monitoring During Anesthesia
103/108
103
7-5 a Normal CO2 waveform
b CO2 drop to zero Disconnection
c CO2 decrease gradually
hyperventilation
d CO increase raduall h oventilation
8/14/2019 8-Monitoring During Anesthesia
104/108
104
PARTPART
OTHER SYSTEMOTHER SYSTEM
Measurement ofMeasurement of
8/14/2019 8-Monitoring During Anesthesia
105/108
105
easu e e o
TemperatureTemperature General anaesthesia inhibits the patientsGeneral anaesthesia inhibits the patients
ability to maintain body temperature byability to maintain body temperature by
depressing the thermoregulatory centre indepressing the thermoregulatory centre in
the hypothalamusthe hypothalamus
Heat loss during anaesthesia is potentiatedHeat loss during anaesthesia is potentiated
by surgery of long duration and exposure oby surgery of long duration and exposure of
large surface areas of tissue, e.g. thelarge surface areas of tissue, e.g. the
abdominal contents during gastrointestinalabdominal contents during gastrointestinal
operations.operations.
Measurement ofMeasurement of
8/14/2019 8-Monitoring During Anesthesia
106/108
106
TemperatureTemperature The use of wet packs and dry inspiredThe use of wet packs and dry inspired
gases compounds the problem.gases compounds the problem.
These sources of heat loss assume These sources of heat loss assume
even more importance in children,even more importance in children,
especially small babies, whose surfaceespecially small babies, whose surface
area is much larger in proportion toarea is much larger in proportion to
body weight than in the adult.body weight than in the adult.
Measurement ofMeasurement of
8/14/2019 8-Monitoring During Anesthesia
107/108
107
TemperatureTemperature
1. The operating room temperature should be as high1. The operating room temperature should be as high
as is comfortable for the theater staff.as is comfortable for the theater staff.
2. A warming mattress should be placed beneath the2. A warming mattress should be placed beneath the
patient.patient.3. Exposed surfaces should be swaddled with warm3. Exposed surfaces should be swaddled with warm
gauze or foil, especially in neonates.gauze or foil, especially in neonates.
4. All i.v. infusion fluids should be warmed.4. All i.v. infusion fluids should be warmed.
5. Inspired gases should be warmed and humidified.5. Inspired gases should be warmed and humidified.
easurement to minimize heat loss
Measurement ofMeasurement of
8/14/2019 8-Monitoring During Anesthesia
108/108
TemperatureTemperature
1. The nasopharynx (approximates to brain1. The nasopharynx (approximates to brain
temperature)temperature)
2. The oesophagus (approximates to cardiac2. The oesophagus (approximates to cardiac
temperature).temperature).
3. The tympanic membrane (best for core3. The tympanic membrane (best for core
temperature, but the membrane is delicate andtemperature, but the membrane is delicate and
easily damaged)easily damaged)
4. The rectum.4. The rectum.
The probe may be placed in thefollowing positions in order to measurecore temperature: