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Monitoring in Anesthesia

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but the father of anesthesia monitoring Invented and popularized the anesthetic chart Recorded both BP and HR Emphasized the relationship between vital signs and ... – PowerPoint PPT presentation

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Title: Monitoring in Anesthesia


1
Monitoring in Anesthesia
  • ??.????????? ?????????????
  • ?.?., ?. ???????????????????????, ??.(???????)
  • ???????????????????
  • ???????????????????????????????
  • ?????????????

2
Topic module
  • 1.?????????????????????????????????????????
  • 2.????????????????????????????????????????????????
    ?
  • 3.?????????????????????????????????????????????
  • ( NIBP , SpO2 , ECG , ET-CO2 )

3
Contents
  • Introduction
  • What is monitoring?
  • Which, Why and How to monitor?
  • Level of monitoring
  • Standards for basic intraoperative monitoring (
    ASA)
  • Systematic monitoring
  • Conclusion

4
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)

5
What is monitoring?
  • to monere (????????????, ???????????)
  • Physiologic parameter Patient safety parameter
  • Clinical skills Monitoring equipment
  • Data collection, interpretation, evaluation,
    decision
  • Problem seeking, Severity assessment, Therapeutic
    assessment, Evaluation of Anesthetic
    interventions

6
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)

7
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)

8
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 patients respiratory
    (ventilation, oxygenation), circulation and
    temperature shall be continually evaluated

9
Monitoring in the Past
  • Visual monitoring of respiration and overall
    clinical appearance
  • Finger on pulse
  • Blood pressure (sometimes)

10
Monitoring in the Past
Finger on the pulse
11
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 )

12
Examples of Multiparameter Patient Monitors
13
Transesophageal Echocardiography
Depth of Anesthesia Monitor
Evoked Potential Monitor
Some Specialized Patient Monitors
14
Cardiovascular monitoring
  • Routine monitoring
  • Cardiac activity
  • Non-invasive blood pressure ( NIBP )
  • Electrocardiography ( ECG )
  • Advanced monitoring
  • Direct arterial blood pressure
  • Cardiac filling pressure monitor
  • Central venous pressure
  • Pulmonary capillary wedge pressure

15
Cardiovascular monitoring
  • Electrocardiography
  • Cardiac activity
  • Arrhythmia Lead II
  • Myocardial ischemia ECG criteria
  • Electrolyte imbalance
  • Pacemaker function

16
Cardiovascular monitoring
  • ??????? ECG
  • 1. ?????? lead II, modified V5
  • 2. ???????? ?????? ????????
  • -arrhythmia bradycardia, tachycardia, AF,
    PVC, VT, VF
  • -Myocardial ischemia
  • -electrolyte imbalance

17
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
  • ???????
  • ????????????
  • ????????????????
  • ????????? ???????????????????????????????????
  • ??????????????????????????????????????

18
Cardiovascular monitoring
  • Non-invasive blood pressure
  • Inaccurate cuff size, inflated pressure,
    shivering, cardiac arrhythmia, severe
    vasoconstriction

Proper application
Narrow cuff
Loose cuff
19
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

20
Cardiovascular monitoring
  • Direct arterial pressure monitor
  • Contraindications
  • Local infection
  • Impaired blood circulation Raynauds phenomenon,
    DM
  • Risks of thrombosis hyperlipidemia, previous
    brachial artery cannulation
  • Modified Allens test ??? ( ??????????????????????
    ???)

21
Cardiovascular monitoring
  • Direct arterial pressure monitor
  • Complications
  • Direct trauma AV-fistula, Aneurysm
  • Hematoma
  • Infections
  • Thrombosis
  • Embolization
  • Massive blood loss

22
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

23
Cardiovascular monitoring
  • Cardiac filling pressure monitor
  • LV Preload ? LVEDV ? LVEDP ? LAP ? PCWP ? PAP
  • LVEDP ? RVEDP ? RAP ? CVP

24
Cardiovascular monitoring
  • Cardiac filling pressure monitor
  • PCWP Pulmonary capillary wedge pressure
  • CVP Central venous pressure

25
Cardiovascular monitoring
  • PCWP Pulmonary capillary wedge pressure
  • CVP Central venous pressure
  • Fluid Challenge test to optimize preload and
    maximize Cardiac performance

26
Respiratory monitoring
  • Ventilatory monitoring
  • Oxygenation monitoring
  • Machine and Circuit monitoring
  • Clinical skills
  • Monitoring devices

27
Ventilatory monitoring
  • Clinical skills
  • Direct observation rate, rhythm, volume of
    respiration
  • Auscultation precordial, esophageal stethoscope
  • Palpation reservoir bag movement
  • Monitoring devices
  • Spirometer
  • Airway pressure manometer
  • Circuit disconnection alarm

28
Ventilatory monitoring
  • Capnometer (End-tidal CO2 analysis)
  • relationship with PaCO2 ETCO2 lt PaCO2 3-6
    mmHg
  • mainly depends on dead space ventilation
  • normal value 30 35 mmHg
  • Infrared absorption spectrography
  • Main-stream VS. Side-stream

29
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
3
2
1
30
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

31
??????? (????? waveform of ET-CO2 ?????????)
  • Capnograph
  • -esophageal intubation
  • -bronchial intubation
  • -airway obstruction
  • -circuit disconnect
  • -circuit leakage
  • -partial rebreathing
  • -spontaneous breathing (recovary of neuromuscular
    blockade)
  • -hypoventilation

32
Oxygenation monitoring
  • Clinical skills
  • Direct observation impaired mental function,
    sympathetic overactivities, appearance(
    cyanosis)
  • Auscultation wheezing, crepitation
  • Monitoring devices
  • Arterial blood gas analysis
  • Percutaneous O2 measurement
  • Pulse oximeter

33
Oxygenation monitoring
  • Pulse oximeter
  • Percent of oxyhemoglobin / total hemoglobin
  • Oxyhemoglobin absorp 940 nm.
  • Deoxyhemoglobin absorp 660 nm.
  • Caution SpO2 ? PaO2

34
Oxygenation monitoring
  • Pulse 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)

35
Oxygenation monitoring
  • Pulse oximeter artifacts
  • Abnormal hemoglobin COHb, MetHb, HbF
  • Dye Methylene blue
  • Anemia
  • Ambient light
  • Arterial saturation
  • Blood flow
  • Motion
  • Nail polish
  • Electro-cautery

36
???????
  • Wave form Pulse oximeter
  • Pulse oximeter artifacts ???????????????????????
  • Cause of Rt-Lt shift of oxygen-hemoglobin
    dissociation curve

37
Machine circuit monitoring
  • Safety system
  • DISS, PISS, Quick disconnection adaptor
  • Oxygen fail-safe valve, Oxygen supply failure
    alarm
  • Oxygen analyzer
  • Airway gas composition
  • Clinical skills flowmeters, vaporizers
  • Monitoring devices Infrared spectrometer

38
Depth of Anesthesia
  • Clinical Signs
  • eye signs
  • respiratory signs
  • cardiovascular signs
  • CNS signs
  • EEG monitoring
  • Facial EMG monitoring (experimental)
  • Esophageal contractility (obsolete)

39
Neurologic monitoring
  • Depth of anesthesia ( BIS )
  • EEG
  • Evoked potentials
  • Cerebral blood flow
  • Intracranial pressure

40
Neuromuscular monitoring
  • Clinical skills
  • Monitoring device
  • PERIPHERAL NERVE STIMULATOR

41
Volume status and renal monitoring
  • Estimate blood loss
  • Urine output
  • Hemodynamic stability

42
Volume status and renal monitoring
  • Estimate blood loss
  • Urine output
  • Hemodynamic stability

43
Electrolyte / Metabolic monitoring
  • Fluid balance
  • Sugar
  • Electrolytes
  • Acid-base balance

44
Coagulation Monitoring
  • PT / PTT / INR
  • ACT
  • Platelet counts
  • Factor assays
  • TEG
  • Clinical sign

45
Temperature monitoring
  • 4 mechanism of heat loss
  • Perioperative hypothermia (BTlt36)
  • Core temperature nasopharynx, esophageal,
    tympanic membrane, pulmonary a. catheter,
    bladder, rectum

46
Temperature Monitoring
  • Rationale for use
  • detect/prevent hypothermia
  • monitor deliberate hypothermia
  • adjunct to diagnosing MH
  • monitoring CPB cooling/rewarming

47
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

48
Conclusion????????????????????????????????????
???????????? out ??????? NIBP,ECG,ET-CO2,SpO2
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