Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Monitoring in Anaesthesia
and Intensive Care
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?
Physiologic parameter & Patient safety parameter
Clinical skills & Monitoring equipment
Data collection, interpretation, evaluation, decision
Problem seeking, Severity assessment, Therapeutic
assessment, Evaluation of Anesthetic interventions
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)
Standard II
During all anesthetics, the patients respiratory
(ventilation, oxygenation), circulation and temperature
shall be continually evaluated
Monitoring in Anesthesia
OBJECTIVES:
1. Guidelines to the practice of anesthesia and patient monitoring
2. Elements to monitor
(Anesthesia depth, Oxygenation, Ventilation, Circulation, Temperature)
2.1. ECG
2.2. Pulse Oximetry ( Function, Values, Limitations)
2.3. Blood Pressure (methods, indications, limitations, Insertion sites, values)
2.4. central venous line and pressure (methods, indications, limitations,
Insertion sites and it's advantages, Complications, values)
8
Monitoring in Anesthesia
OBJECTIVES:
2.5. Capnography and EtCO2 (Uses, Measurement, values, factors
affecting EtCO2)
2.6. Cyanosis
2.7. The oxyhemoglobin dissociation curve (interpretation, causes of
Left and right shifting , key values, O2-Content of Blood)
2.8. Temperature ( Methods, Values, sites)
Monitoring in the
Past
Finger on the
pulse
Harvey Cushing
Not just a famous neurosurgeon
but the father of anesthesia monitoring
Invented and popularized
chart
the anesthetic
3. An anesthetic record.
-
also time, dose and route of drugs and fluids should be charted
oxygenation
ventilation
circulation
temperature
!
14
MONITORING
HR
O2 sat
RR
BP
Temp
MAP
15
Elements to Monitor :
I. Anesthetic Depth:
Patients with local or regional anesthesia provide verbal
feedback regarding well being.
Onset of general anesthesia signaled by lack of response to
verbal commands, in addition to loss of blink reflex to light
touch.
Inadequate anesthesia can be signaled by : Facial grimacing or
movement of arm or leg. But with muscle relaxants ( fully
paralysis), it can be signaled by : Hypertension, tachycardia,
tearing or sweating.
Excessive anesthesia can be signaled by :
Cardiac depression, bradycardia, and Hypotension.
And also may result in hypoventilation, hypercapnia and
hypoxemia when muscle relaxants is not given.
16
Elements to Monitor :
II. Oxygenation:
Clinically, monitored by patient color ( with adequate
illumination ) and pulse oximetry.
Quantitavely monitored by using oxygen analyzer, equipped
with an audible low oxygen concentration alarm.
III. Temperature
Continuous temperature measurements monitoring is
mandatory if changes in temperature are anticipated or
suspected.
17
Elements to Monitor :
IV. Circulation:
Clinically, monitored by pulse palpation, heart auscultation
and monitoring intra-arterial pressure or oximetry.
Quantitavely using ECG signals and arterial blood pressure
measurements every 5 min.
V. Ventilation
Clinically, monitored through a correctly positioned
endotracheal tube, also observing chest excursions, reservoir
bag displacement, and breath sounds over both lungs.
Quantitavely by ETCO2 analysis, equipped with an audible
disconnection alarm.
Arterial blood gas analysis for assessing both oxygen and
ventilation.
18
Monitoring:
Electrocardiogram ECG:
The 3 lead system has electrodes positioned on the right arm, left arm and
chest position. ( placed in the left anterior axillary line at the 5 th interspace,
referred to as V5 ). Lead II is usually monitored by this system.
The 5 lead system adds a right leg and left leg electrodes, which allows
monitoring v1, v2, v3, AVR, AVL, AVF and V5.
ST segment
19
Monitoring:
Electrocardiogram ECG:
Monitoring:
Pulse Oximetry:
21
PULSEOXIMETRY is for
OXYGENATION
Principle : Spectrophotometry &
Plethysmography
relies on the differing absorption of light, at different wavelengths by
the various states of oxyhaemoglobin
- HbO2 has a higher absorption at 940 nm (blue light)
S p O2
C HbO2
C HbO2 C Hb
Monitoring:
o Methods of BP measurement:
MEASUREMENT OF ARTERIAL
PRESSURE
INDIRECT measurement (non-invasive)
- signals generated by the occlusion of a major artery using a cuf
- gives not continous but intermittent measurements
LIMITATIONS:
-
Cuff Size
Too small cuff will result in false high blood pressure
reading
fr
o
m
B
ar
ba
ra
B
at
es
:
A
G
ui
de
to
Ph
ys
ic
al
Ex
a
mi
na
ti
on
METHODS
Electromechanical TRANSDUCERS
The diaphragm :
- is moved by arterial pulsations which push the saline column
- should be thin, small and rigid !
Transducers :
- based upon strain gauge principle : stretching (by PRESSURE ) a
wire or silicone crystal changes its electrical resistance
- connected to a wheatstone bridge circuit : so that the voltage
output is proportionate to the pressure applied it
MONITORING SYSTEM
The RF should be at least at least 5 times higher than the highest
frequency in the input signal or better : approx.10 times the FF
at least FR >20 Hz to avoid ringing and systolic
overshoot
optimal damping
- underdamping = overestimates SAP and underestimates DAP
- overdamping = underestimates SAP and overestimates DAP
- both cases however MAP is relatively accurate
Monitoring:
o Methods of BP measurement:
Monitoring:
o Methods of BP measurement:
40
42
43
44
External jugular:
45
46
SWAN GANZ = PA
CATHETER
SWAN-GANZ catheter
Waveform during Insertion
PA CATHETER
PA CATHETER
Zone III allows for
uninterrupted blood
flow and a
continuous
communication
with distal
intracardiac
pressures. (PAand
PV exceed Palv)
PAC-Thermodilution
Decreased ETCO2
Hypothermia
Hypometabolism
Hyperventilation
Hypoperfusion
Embolism
Normal
Esophageal 0 !
> 4 curves
Cardiac arrest
Curare cleft
bronhospasm
spontaneous
IMV
Expiratory Valve
Inspiratory valve
Cyanosis:
Defined as the presence of 5 g./dL of deoxygenated
hemoglobin (deoxy Hb).
i.e. Hb level = 15 g/dL, 5 g/dL release O2 which leaves 10 g/dL of
oxyhemoglobin
SaO2 = OxyHb / (OxyHb + DeoxyHb) = 10 / (10 + 5) = 66%
SaO2 of 66% corresponds to PaO2 of 35mmHg.
Left
Causes:
Inc. PCO2
Hyperthermia
Acidosis
Increased altitude
Increased 2,3-DPG
Sickle Cell Anemia
Inhalational anesthetics
Causes:
Dec. PCO2
Hypothermia
Alkalosis
Fetal hemoglobin
Decreased 2,3-DPG
Carboxyhemoglobin
Methemoglobin
Monitoring Temperature
Objective
Application
Methods
thermostat
temperature sensitive chemical reactions
Monitoring Temperature
Potential heat loss or risk of hyperthermia
necessitates continuous temperature
monitoring
Normal heat loss during anesthesia averages
0.5 - 1 C per hour, but usually not more that 2
-3C
Temperature below 34C may lead to
significant morbidity
Monitoring Temperature
Hypothermia develops when thermoregulation
fails to control balance of metabolic heat
production and environment heat loss
Normal response to heat loss is impaired
during anesthesia
Those at high risk are elderly, burn patients
neonates, spinal cord injuries
Monitoring Temperature
Hyperthermia Causes
Malignant hyperthermia
Endogenous pyroxenes (IL1)
Excessive environmental warming
Increases in metabolic rate secondary to:
Thyrotoxicosis
Pheochromocytoma
Monitoring Temperature
Monitoring Sites
Tympanic
Esophagus
Rectum
Nasopharynx
67
SBP
DBP
HR
RR
SpO2
ETCO2
CVP
PAP
(mean)
PCWP
85
160
50 95
50
100
8 20
95
100
33 45
warm,
dry
pink
36
37.5
>= 0.5
mmHg
mmHg
bpm
rpm
%
mmHg
1 10
10 20
5 15
75
mmHg
mmHg
mmHg
%
C
ml.kg1
.min-1
O
68
THANK
YOU
69
Clinical measurement
is limited by 4 major constraints:
1. Feasibility
2. Reliability
3.
Interpretation
4.
Value
Digital instruments
- non-electrical signals are converted by a transducer to an electrical
- calibration is important
( against predetermined signals or for absolute measurements to zero)
MECHANICAL SIGNALS:
MEASUREMENT OF ARTERIAL PRESSURE
a wide range of instruments are used to measure pressure :
liquid column manometers : height, zero point, fluid density
The Nexfin HD
A truly noninvasive CCO
monitor
Fick metdod
Indicator dilution
Pulse waveform ( pulse contour) methods
ULTRASOUNDS ( 2D-Echo and Doppler
techique)
Bioimpedance
ANGIOGRAPHY
MRI
but :
INDICATOR DILUTION
Chemical indicator dilution (dye)
INDICATOR DILUTION
TD Methods :
1.
1.
PAC-Thermodilution
Loss of indicator
Variation of injectate temperature and volume
Recirculation - IC shunts : false high CO values
Tricuspid regurgitation : false low CO values
Fluctuations in baseline temperature
...........................
10 ml.
cold
optimal < 4 sec.
> 4-5 sec. false low CO
! at least 3 measurements and less than < 10 % between
them
Advantages of P-TD
PULMONARY Thermodilution
Thermodiution
TRANSPULMONARY
The pulmonary artery TD curve appears earlier and has a higher peak
temperature than the femoral artery TD curve.
TP-TD is less invasive than P-TD, but does NOT give : SvO2 an PAP
values !
1. CALIBRATED techniques
PiCCO
LiDCO Pulse CO
2. NON-CALIBRATED techniques
Flow-Track VIGILEO
Nexfin
SV
PiCCO
LiDCO Pulse CO
Lithium indicator
Dilution
NEXFIN
- totally non-invasive
BIOIMPEDANCE
TB ~ stroke volume
SV = K x (dZ / dt) / Zo x TEV
Doppler - method
Ultrasounds (1.)
US techniques can detect : the shape, size and
movement of tissue interfaces, especially soft tissues
and blood (RBC)
US are defined by :
- amplitude of oscillation (delta pressure : ambient to peak) dB
- the wavelength (distance between successive peaks)
- frequency (inversely proportional to wavelength, nr. of cycles / second )
Ultrasounds (2.)
Transducers :
- generate and sense US
- are made from ceramic materials able to transform mechanical
energy (pressure) to electrical energy and vice versa ( the
piezoelectric effect )
- Transducers : generates ultrasound of the same frequency
as the applied voltage
2-D Method
Principle
150 ml - 52 ml= 98 ml
Doppler Effect - 3
Doppler effect represented by:
V=
_F . c _
2 F0 cos
Where V = velocity of object
F = frequency shift
c = speed of sound in medium (body tissue here)
F0 = frequency of emitted sound
cos = angle between sound wave and flow (RBC)
cos 90 = 0
Doppler Method
Principle
D=2.1 cm
Simplified formula= (2.1cm)2 * 0.785
3.46cm
X 25cm = 87 cm3
OESOPHAGEAL DOPPLER
Measurement of blood flow velocity in the descending
aorta at the tip of the flexible probe
CO (cardiac output)
SV (stroke volume)
FTc (corrected f low time)
PV (peak velocity)
MD (minute distance)
HR (heart rate)