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Monitoring During anaesthesia

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Monitoring During anaesthesia Prof. Abdulhamid Al-Saeed, FFARCSI Anaesthesia Department ... The presence of end tidal CO2 aids in confirming endotracheal intubation. – PowerPoint PPT presentation

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Title: Monitoring During anaesthesia


1
Monitoring During anaesthesia
  • Prof. Abdulhamid Al-Saeed, FFARCSI
  • Anaesthesia Department
  • College of Medicine
  • King Saud University

2
Lecture Objectives..Students at the end of the
lecture will be able to knows
  • Monitors
  • Non-invasive blood pressure , ECG , pulse
    oximetry capnography (CO2 monitor) and oxygen
    analyzer , temperature probe nerve stimulator
  • Specialized monitors
  • arterial line (invasive blood pressure)
  • central venous line (cvp monitoring)
  • pulmonary artery flotation catheter ( monitors
    function of right and left side of the heart)
  • BIS monitor (depth of anesthesia)

3
Monitoring A Definition
  • interpret available clinical data to help
    recognize present or future mishaps or
    unfavorable system conditions

4
Monitoring in the Past
  • Visual monitoring of respiration and overall
    clinical appearance
  • Finger on pulse
  • Blood pressure (sometimes)

Finger on the pulse
5
Monitoring in the Present
  • Standardized basic monitoring requirements
    (guidelines) from the ASA (American Society of
    Anesthesiologists), CAS (Canadian
    Anesthesiologists Society) and other national
    societies
  • Many integrated monitors available
  • Many special purpose monitors available
  • Many problems with existing monitors (e.g., cost,
    complexity, reliability, artifacts)

6
Standard
  • ASA monitoring for general anesthesia ,
    monitored anesthesia care and regional anesthesia
    -
  • Oxygenation (oxygen analyzer, pulse oximetry),
  • Ventilation (capnography, minute ventilation),
    respiratory rate (under regional anesthesia)
  • Circulation (electrocardiogram ECG, arterial
    blood pressure, perfusion assessment),
  • Temperature.

7
High Tech Patient Monitoring
Examples of Multiparameter Patient Monitors
8
High Tech Patient Monitoring
Transesophageal Echocardiography
Depth of Anesthesia Monitor
Evoked Potential Monitor
Some Specialized Patient Monitors
9
Cardiovascular system.
  • The circulatory system is responsible for oxygen
    delivery to and removal of waste products from
    the organs, and this must be maintained during
    anesthesia.

10
Signs and symptoms of perfusion abnormalities
  • Central nervous system mental status changes,
    neurologic deficits.
  • Cardiovascular system chest pain, shortness of
    breath, ECG abnormalities, wall motion
    abnormalities on echocardiogram.
  • Renal decreased urine output, elevated blood
    urea nitrogen and creatinine, decreased
    fractional excretion of sodium.
  • Gastrointestinal abdominal pain, decreased bowel
    sounds, hematochezia.
  • Peripheral cool limbs, poor capillary refill,
    diminished pulses.

11
ECG.
  • The ECG monitors the conduction of electrical
    impulses through the heart.
  • Rhythm detection is best seen in lead II.

12
ECG
13
Electrocardiogram
  • Displays the overall electrical activities of the
    myocardial cells
  • Heart rate dysrhythmias
  • Myocardial ischaemia
  • Pacemaker function
  • Electrolyte abnormalities
  • Drug toxicity
  • Does NOT indicate mechanical performance of the
    heart
  • Cardiac output
  • Tissue perfusion

14
  • Full (12)-lead ECG
  • Standard limb leads (bipolar)
  • Precordial leads (unipolar)
  • 5.lead system
  • Unipolar bipolar
  • RA, LA, RL, LL, C
  • 3.lead system
  • Bipolar with RA, LA, LL
  • V5 usually used
  • Best compromise between detecting ischaemia and
    diagnosing arrhythmia
  • May come with ST-segment analysis

15
ECG
Standard Limb Leads Unipolar Chest Leads
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18
Artifacts in ECG Monitoring
  • Loose electrodes or broken leads
  • Misplaced leads
  • Wrong lead system selected
  • Emphysema, pneumothorax, pericardial effusion
  • Shivering or restlessness
  • Respiratory variation and movement
  • Monitor Pulse Oximetry, Invasive ABP

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25
Arterial blood pressure.
  • Automated noninvasive blood pressure is the most
    common noninvasive method of measuring blood
    pressure in the operating room.
  • Invasive blood pressure monitoring uses an
    indwelling arterial catheter coupled through
    fluid-filled tubing to a pressure transducer.
  • The transducer converts pressure into an
    electrical signal to be displayed.
  • Indications
  • Need for tight blood pressure control (e.g.,
    induced hyper- or hypotension).
  • Hemodynamically unstable patient.
  • Frequent arterial blood sampling.
  • Inability to utilize noninvasive blood pressure
    measurements.

26
Arterial Blood Pressure
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28
Central venous pressure (CVP) and cardiac output
  • CVP is measured by coupling the intravascular
    space to a pressure transducer using fluid-filled
    tubing.
  • Pressure is monitored at the level of the vena
    cava or the right atrium.
  • Indications
  • Measurement of the right heart filling pressures
    to assess intravascular volume and right heart
    function.
  • Drug administration to the central circulation.
  • Intravenous access for patients with poor
    peripheral access.
  • Indicator injection for cardiac output
    determination (e.g., green dye cardiac output).
  • Access for insertion of pulmonary artery
    catheter.
  • Range The CVP is normally 2 to 6 mm Hg

29
Central Venous Pressure
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32
PULMONARY ARTERY CATHETER
33
Pulmonary Artery Catheter
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35
Haemodynamic Profiles Obtained from PA Catheters
  • SV CO / HR (60-90 mL/beat)
  • SVR (MAP CVP) / CO ? 80
    (900-1500 dynes-sec/cm5)
  • PVR (MPAP PCWP) / CO ? 80
    (50-150 dynes-sec/cm5)

36
  • O2 delivery (DO2)
  • C.O. ? O2 content
  • Arterial O2 content (CaO2) ( Hb ? 1.38 ) ?
    (SaO2)
  • Mixed venous O2 content (CvO2) ( Hb ? 1.38 ) ?
    (SvO2)
  • O2 consumption (VO2) C.O. ? (CaO2-CvO2)
  • SvO2 SaO2 VO2 / (Hb ? 13.8)(CO)

37
  • Respiratory system.
  • pulse oximetry, capnography, a fraction of
    inspired oxygen analyzer, and a disconnect alarm.
  •  Pulse oximeter
  • combines the principles of oximetry and
    plethysmography to noninvasively measure oxygen
    saturation in arterial blood.
  • The pulse oximeter probe contains two light
    emitting diodes at wavelengths of 940nm and 660
    nm.
  • Oxygenated and reduced hemoglobin differ in light
    absorption (940 and 660 nm respectively).
  • Thus the change in light absorption during
    arterial pulsation is the basis of oximetry
    determination.
  • The ratio of the absorption at the two
    wavelengths is analyzed by a microprocessor to
    record the oxygen saturation.
  •  
  •  

38
Pulse Oximetry
39
Incomptencies
  • Critically ill with poor peripheral circulation
  • Hypothermia VC
  • Dyes ( Nail varnish )
  • Lag Monitor Signalling 5-20 sec
  • PO2
  • Cardiac arrhythmias may interfere with the
    oximeter picking up the pulsatile signal properly
    and with calculation of the pulse rate
  • Abnormal Hb ( Met., carboxy)

40
  • Capnometry
  • What is Capnometry?
  • Is the measurement of end-tidal carbon dioxide
    tension.
  • This provides valuable information to the
    anesthesiologist.
  • The presence of end tidal CO2 aids in confirming
    endotracheal intubation.
  • Alteration in the slope of the graph can give
    clues to the presence of airway obstruction.
  • A rapid fall in reading may signify extubation,
    air embolism or low cardiac output with
    hypovolemia.

41
  • The Alpha angle
  • The angle between phases II and III, which has
  • increases as the slope of phase III increases.
  • The alpha angle is an indirect indication of V/Q
  • status of the lung.
  • Airway obstruction causes an increased
  • slope and a larger angle.
  • Other factors that affect the angle are the
    response time of the capnograph, sweep speed, and
    the respiratory cycle time.
  • The Beta angle
  • The nearly 90 degrees angle between phase III and
    the descending limb in a time capnogram has been
    termed as the beta angle.
  • This can be used to assess the extent of
    rebreathing. During rebreathing, there is an
    increase in beta angle from the normal 90
    degrees.

42
Clinical Applications
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44
Central nervous system (level of consciousness)
monitoring
  • Bispectral index (BIS) assess central nervous
    system depression during general anesthesia.
  • It is based on the surface electroencephalogram
    (EEG), which predictably changes in amplitude and
    frequency as the depth of anesthesia increases.

45
Temperature monitoring
  • Indications
  • Infants and small children are prone to thermal
    lability due to their high surface area to volume
    ratio.
  • Adults subjected to large evaporative losses or
    low ambient temperatures (as occur with exposed
    body cavity, large volume transfusion of unwarmed
    fluids, or burns) are prone to hypothermia.
  • Malignant hyperthermia is always a possible
    complication, and temperature monitoring should
    always be available.

46
  • Monitoring site
  • Tympanic membrane temperature
  • Rectal temperature
  • Nasopharyngeal temperature,
  • Esophageal temperature monitoring reflects the
    core temperature well. The probe should be
    located at the lower third of the esophagus and
    rarely may be misplaced in the airway.
  • Blood temperature measurements may be obtained
    with the thermistor of a PAC.

47
Neuromuscular blockade monitoring
  • Neuromuscular blockade is monitored during
    surgery to guide repeated doses of muscle
    relaxants and to differentiate between the types
    of block.
  • All techniques for assessing neuromuscular
    blockade use a peripheral nerve stimulator (PNS)
    to stimulate a motor nerve electrically.

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49
Detecting Mishaps Using Monitors
  • 8. Pneumothorax
  • 9. Air Embolism
  • 10. Hyperthermia
  • 11. Aspiration
  • 12. Acid-base imbalance
  • 13. Cardiac dysrhythmias
  • 14. IV drug overdose
  • Source Barash Handbook
  • 1. Disconnection
  • 2. Hypoventilation
  • 3. Esophageal intubation
  • 4. Bronchial intubation
  • 5. Circuit hypoxia
  • 6. Halocarbon overdose
  • 7. Hypovolemia

These mishaps
50
Detecting Mishaps with Monitors
  • Pulse oximeter
  • Capnograph
  • Automatic BP
  • Stethoscope
  • Spirometer
  • Oxygen analyzer
  • ECG
  • Temperature
  • 1,2,3,4,5,8,9,11,14
  • 1,2,3,9,10,12
  • 6,7,9,14
  • 1,3,4,13
  • 1,2
  • 5
  • 13
  • 10
  • Source Barash Handbook

are detected using these monitors
51
Question NO. 8
  • 1- Identify the monitor Tracing?
  • 2- What is the Name Cause of the Notch on the
    descending limb of the trace?
  • 3- Name two different Clinical informations could
    be interpreted from this tracing?
  • a) ..
  • b) ..

52
Question NO. 10
  • 1- Identify the Rhythm in the shown ECG Strip?
  • ---------------------------------------------
    ---------
  • 2- What is your first line of management in case
    of Unstable patient
  • 3- What is the normal QRS duration

53
Question NO. 14
  • 1- Identify the tracing
  • 2- Name the different phases of the trace
  • I ?
  • II ? ..
  • III ? .
  • IV ? ..
  • 3- What different clinical informations could be
    interpreted from the trace
  • a) ..
  • b) ..

54
Question NO. 15
  • 1- Name the different waves on the trace?
  • ------------------------------------------------
  • 2- Define Central Venous Pressure?
  • 3- What are the main determinants regulating CVP?
  • A-.
  • B- ...

55
Question NO. 19
  • brief the mechanism of action of this monitor

  • Name 4 factors affecting the accuracy of this
    monitor?
  • If P50 of oxyhemoglobine dissociation curve is
    40 is this curve shifted to the right or left
    mention 3 possible causes?
  • ..

56
  • 36-Each of the following factors may lead to
    error in readings using pulse oximetry EXCEPTA.
    electrocauteryB. high cardiac output statesC.
    infrared lights near the sensorD. intravenous
    dyesE. severe hemodilution
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