6.Monitoring in Anesthesia.ppt

7/28/2019 6.Monitoring in Anesthesia.ppt

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Monitoring in Anesthesia

Imam Ghozali ., dr.,SpAn.,MKes


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Contents

IntroductionWhat is monitoring?

Which, Why and How to monitor?

Level of monitoring

Standards for basic intraoperativemonitoring ( ASA)

Systematic monitoring

Conclusion


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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)


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What is monitoring? to monere

Physiologic parameter & Patient safety parameterClinical skills & Monitoring equipment

Data collection, interpretation, evaluation, decision

Problem seeking, Severity assessment, Therapeuticassessment, Evaluation of Anesthetic interventions


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Patient Monitoring and Management

Involves

Things you measure(physiological measurement, such as

BP or HR)

Things you observe(e.g. observation of pupi ls)

Planning to avoid trouble(e.g. planning induction of

anesthesia or planning extubation)

Inferring diagnoses(e.g. unilateral air entr y may mean

endobronchial intubation)

Planning to get out of trouble(e.g. dif ferential diagnosis

and response algorithm formulation)


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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)


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Standards for basic intraoperative monitoring

( ASA : American Society of Anesthesiologists)

Standard I

Qualified anesthesia personnel shall be present in theroom throughout the conduct of all GA, RA, MAC

Standard II

During all anesthetics, the patients respiratory(ventilation, oxygenation), circulation and temperatureshall be continually evaluated


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Monitoring in the PastVisual monitoring ofrespiration and

overall clinicalappearance

Finger on pulse

Blood pressure(sometimes)


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Monitoring in the Past

Finger on the pulse


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Harvey CushingNot 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 andneurosurgical events( increased intracranial pressure leads to

hypertension and bradycardia )


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Examples of Multiparameter Patient Monitors


12/46Some Specialized Patient Monitors

Depth of Anesthesia Monitor

Evoked Potential Monitor

TransesophagealEchocardiography


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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


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Electrocardiography

Cardiac activity

Arrhythmia: Lead IIMyocardial ischemia: ECG criteria

Electrolyte imbalance

Pacemaker function


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ECG1. lead II, modified V5

-arrhythmia : bradycardia, tachycardia, AF,PVC, VT, VF

-Myocardial ischemia

-electrolyte imbalance


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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


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Cardiovascular monitoringNon-invasive blood pressure

Inaccurate: cuff size, inflated pressure, shivering,

cardiac arrhythmia, severe vasoconstriction

Proper application Narrow cuff Loose cuff


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Cardiovascular monitoringDirect 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


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Contraindications

Local infection

Impaired blood circulation: Raynauds

phenomenon, DM

Risks of thrombosis: hyperlipidemia, previous

brachial artery cannulationModified Allens test ???


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Complications

Direct trauma: AV-fistula, Aneurysm

Hematoma

Infections

Thrombosis

Embolization

Massive blood loss


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Cardiovascular monitoringCardiac 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 LAPPCWP PAP RVP RAP CVP

Myocardium function, LV compliance, Mitral valve, Airwaypressure, Pulmonary vascular resistance, Pulmonic valve,

Tricuspid valve


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LV Preload LVEDV LVEDP LAP PCWPPAP

LVEDP RVEDP RAP CVP


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PCWP: Pulmonary capillary wedge pressure

CVP: Central venous pressure


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PCWP: Pulmonary capillary wedge pressure

CVP: Central venous pressure

Fluid Challenge test to optimize preload and

maximize Cardiac performance


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Respiratory monitoring Ventilatory monitoring

Oxygenation monitoring

Machine and Circuit monitoringClinical skills

Monitoring devices


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Ventilatory monitoringClinical 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


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Ventilatory monitoringCapnometer(End-tidal CO2analysis)

relationship with PaCO2 : ETCO2 < PaCO2 ~ 3-6 mmHg

mainly depends on dead space ventilationnormal value 30 35 mmHg

Infrared absorption spectrography

Main-stream VS. Side-stream


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Ventilatory monitoringCapnogram : normal curve

1. Dead space air (no CO2)

2. Mixed bronchus & alveolus air (CO2 upstroke)

3. Alveolus air (CO2 plateau)

InspirationETCO2

1 23


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Ventilatory monitoringCapnometer (End-tidal CO2 analysis)

Most useful in detection of Esophageal intubation,

airway or circuit disconnectionUseful in CO2 rebreathing, partial recovery of neuro-

muscular blockade, good predictor of successful CPR


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waveform of ET-CO2

Capnograph

-esophageal intubation

-bronchial intubation

-airway obstruction

-circuit disconnect

-circuit leakage

-partial rebreathing

-spontaneous breathing (recovary of neuromuscular blockade)

-hypoventilation


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Oxygenation monitoringClinical skills

Direct observation: impaired mental function,

sympathetic overactivities, appearance(+ cyanosis)

Auscultation: wheezing, crepitation

Monitoring devices

Arterial blood gas analysis

Percutaneous O2 measurement

Pulse oximeter


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Pulse oximeter

Percent of oxyhemoglobin

/ total hemoglobinOxyhemoglobin absorp

940 nm.

Deoxyhemoglobin absorp660 nm.

Caution: SpO2 PaO2


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Pulse oximeterSpO2 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)


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Oxygenation monitoring Pulse oximeter artifactsAbnormal hemoglobin: COHb, MetHb, HbF

Dye: Methylene blue

AnemiaAmbient light

Arterial saturation

Blood flow

Motion

Nail polish

Electro-cautery


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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


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Depth of Anesthesia

Clinical Signs

eye signs

respiratory signs

cardiovascular signs

CNS signs

EEG monitoring

Facial EMG monitoring (experimental)

Esophageal contractility (obsolete)


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Neurologic monitoringDepth of anesthesia ( BIS )

EEG

Evoked potentials

Cerebral blood flow

Intracranial pressure


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Neuromuscular monitoring

Clinical skills

Monitoring device :

PERIPHERAL NERVE STIMULATOR


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Volume status and renal monitoring

Estimate blood loss

Urine output

Hemodynamic stability


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Volume status and renal monitoring

Estimate blood loss

Urine output

Hemodynamic stability


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Electrolyte / Metabolic monitoring Fluid balance

Sugar

Electrolytes

Acid-base balance


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Coagulation Monitoring

PT / PTT / INR ACT

Platelet counts

Factor assays

TEG Clinical sign


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Temperature monitoring

4 mechanism of heat loss

Perioperative hypothermia (BT


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Temperature Monitoring

Rationale for use

detect/prevent hypothermia

monitor deliberate hypothermia adjunct to diagnosing MH

monitoring CPB cooling/rewarming


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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


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Conclusion

NIBP,ECG,ET-CO2,SpO2

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