Monitoring in Anesthesia

Imam Ghozali ., dr.,SpAn.,MKes

Contents
Introduction

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

What

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?
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

Patient Monitoring and Management Involves

Things

you measure (physiological measurement, such as you observe (e.g. observation of pupils)

BP or HR)
Things

Planning

to avoid trouble (e.g. planning induction of

diagnoses (e.g. unilateral air entry may mean to get out of trouble (e.g. differential diagnosis

anesthesia or planning extubation)

Inferring

endobronchial intubation)
Planning

and response algorithm formulation)

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)

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 all anesthetics, the patients respiratory (ventilation, oxygenation), circulation and temperature shall be continually evaluated

Standard II
During

Monitoring in the Past

Visual

monitoring of respiration and overall clinical appearance Finger on pulse Blood pressure (sometimes)

Monitoring in the Past

Finger on the pulse

Harvey Cushing
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 )

Not just a famous neurosurgeon but the father of anesthesia monitoring

Examples of Multiparameter Patient Monitors

Transesophageal Echocardiography

Depth of Anesthesia Monitor

Evoked Potential Monitor

Some Specialized Patient Monitors

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

Cardiovascular monitoring
Electrocardiography
Cardiac

activity Arrhythmia: Lead II Myocardial ischemia: ECG criteria Electrolyte imbalance Pacemaker function

Cardiovascular monitoring

ECG 1. lead II, modified V5

-arrhythmia : bradycardia, tachycardia, AF, PVC, VT, VF -Myocardial ischemia -electrolyte imbalance

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

Cardiovascular monitoring
Non-invasive blood pressure
Inaccurate:

cuff size, inflated pressure, shivering, cardiac arrhythmia, severe vasoconstriction

Proper application

Narrow cuff

Loose cuff

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, Acidbase / electrolyte / glucose disturbance, Coagulopathies

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

???

Cardiovascular monitoring
Direct

arterial pressure monitor

Complications Direct trauma: AV-fistula, Aneurysm Hematoma Infections Thrombosis Embolization Massive blood loss

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

Cardiovascular monitoring
Cardiac

filling pressure monitor

LV Preload LVEDV LVEDP LAP PCWP PAP LVEDP RVEDP RAP CVP

Cardiovascular monitoring
Cardiac

filling pressure monitor

PCWP: Pulmonary capillary wedge pressure CVP: Central venous pressure

Cardiovascular monitoring
PCWP: Pulmonary capillary wedge pressure CVP: Central venous pressure

Fluid Challenge test to optimize preload and maximize Cardiac performance

Respiratory monitoring
Ventilatory monitoring

Oxygenation monitoring
Machine and Circuit
Clinical

monitoring

skills Monitoring devices

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

Ventilatory monitoring
Capnometer (End-tidal CO2
relationship with

analysis)

PaCO2 : ETCO2 < PaCO2 ~ 3-6 mmHg mainly depends on dead space ventilation normal value 30 35 mmHg Infrared absorption spectrography Main-stream VS. Side-stream

Ventilatory monitoring
Capnogram :
1.

normal curve

Dead space air (no CO2) 2. Mixed bronchus & alveolus air (CO2 upstroke) 3. Alveolus air (CO2 plateau)
1 2

Inspiration

ETCO2

Ventilatory monitoring
Capnometer (End-tidal CO2
Most

analysis)

useful in detection of Esophageal intubation, airway or circuit disconnection Useful in CO2 rebreathing, partial recovery of neuromuscular blockade, good predictor of successful CPR

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

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

Oxygenation monitoring
Pulse oximeter
Percent

of oxyhemoglobin / total hemoglobin Oxyhemoglobin absorp 940 nm. Deoxyhemoglobin absorp 660 nm. Caution: SpO2 PaO2

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)

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

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

Depth of Anesthesia

Clinical Signs

eye signs respiratory signs cardiovascular signs CNS signs

EEG monitoring Facial EMG monitoring (experimental)

Esophageal contractility (obsolete)

Neurologic monitoring
Depth

of anesthesia ( BIS )

EEG
Evoked

potentials Cerebral blood flow Intracranial pressure

Neuromuscular monitoring
Clinical

skills Monitoring device : PERIPHERAL NERVE STIMULATOR

Volume status and renal monitoring

Estimate

blood loss Urine output Hemodynamic stability

Volume status and renal monitoring

Estimate

blood loss Urine output Hemodynamic stability

Electrolyte / Metabolic monitoring

Fluid balance Sugar Electrolytes Acid-base balance

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

Temperature monitoring
4

mechanism of heat loss Perioperative hypothermia (BT<36) Core temperature : nasopharynx, esophageal, tympanic membrane, pulmonary a. catheter, bladder, rectum

Temperature Monitoring
Rationale for use

detect/prevent hypothermia
monitor deliberate hypothermia adjunct to diagnosing MH monitoring CPB cooling/rewarming

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

Conclusion

NIBP,ECG,ET-CO2,SpO2