Anaesthesia Monitoring

BY DR JOGESH AHUJA

PURPOSE OF MONITORING
Monere-to warn.
Measure physiological variables Indicate trends of change Enable appropriate therapeutic action to be taken

STANDARDS OF BASIC ANAESTHESIA MONITORING

Apply to all anesthesia care although, in emergency Circumstances, appropriate life support measures take precedence
Apply to all general anesthetics, regional anesthetics, and monitored care

They are intended to encourage quality patient care, but observing them cannot guarantee any specific patient outcome
These standards are not intended for application to the care of the obstetric patient in labor or in the conduct of pain management

STANDARDS
I Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care
II During all anesthetics, the patient's oxygenation, ventilation, circulation, and temperature shall be continually evaluated
Oxygenation To ensure adequate oxygen concentration in the inspired gas and the blood during all anesthetics Ventilation To ensure adequate ventilation of the patient during all anesthetics Circulation To ensure the adequacy of the patient's circulatory function during all anesthetics Body Temperature To aid in the maintenance of appropriate body temperature during all anesthetics

MONITORING DURING ANAESTHESIA

The cardiovascular system
The respiratory system The depth of anaesthesia Temperature

Monitoring during anesthesia

Monitoring during anesthesia

THE CARDIOVASCULAR MONITORING

Non invasive Blood Pressure Monitoring
Also called as Indirect blood pressure monitoring Peak pressure generated during systolic contraction systolic BP Trough pressure during diastolic relaxation Diastolic BP Pulse pressure is difference between systolic and diastolic BP Mean Blood pressure (MAP) is time weighted average BP during a pulse cycle MAP = SBP + 2 DSP 3

Indication use of any anaesthetic Methods Palpation; Doppler; Auscultation; Oscillometry Contraindications avoided in extremities with vascular abnormalities

THE CARDIOVASCULAR MONITORING

Invasive Arterial Blood Pressure Monitoring
Also called as Direct arterial blood pressure

Indications - induced hypotension, anticipation of wide blood pressure swings, end-organ disease necessitating precise beat-tobeat blood pressure regulation, and the need for multiple arterial blood gas analyses Method by direct cannulation of artery Contraindication arteries without extremities with vascular insufficiency collateral blood flow,

Commonly used is Radial artery, Ulnar artery, Brachial Artery; Lower limb arteries are best avoided

THE CARDIOVASCULAR MONITORING

Cardiovascular system is montiored by
Blood Pressure
Non invasive and invasive

ECG

Cardiovascular Monitoring is useful in

Hypotension Hypertension Myocardial Ischemia Arrhythmias

THE CARDIOVASCULAR MONITORING

ELECTROCARDIOGRAPHY (ECG)
Indications All patients should have intraoperatively ECG monitoring Contraindications there are no contraindications ECG detects
Myocardial Ischemia Arrhythmias

THE CARDIOVASCULAR MONITORING

Hypotension
Reasons
patient's conditions: electrolyte disorder, cardiovascular disease anethesia:drugs, anesthesia method surgery:bleeding, drag

Treatment
anesthesia deep volume nerve reaction vasoactive drugs

THE CARDIOVASCULAR MONITORING

Hypertension
Reasons
Inadequate anaesthesia or analgesia Irritation of intubation and extubation Fast absorption of adrenaline Hypoxia and carbon dioxide retention Catecholamine secretion Intracranial pressure increase Complication: primary hypertension, pregnancy induced hypertension

Treatment
Remove aetiology Vasoactive drugs

THE CARDIOVASCULAR MONITORING

Myocardial Ischemia
Reasons
Stress Blood pressure severe change during surgery Arrhythmia Disorder of ventilation function

Treatment
Treat the cause Anti Ischemia measures eg Nitrocontin, adjusting ventilator function

THE RESPIRATORY SYSTEM MONITORING

Symptoms and signs
Breath holding Breath fast Bronchus spasm Apnoea Laryngeal spasm

Respiratory function:
Tidal volume, minute ventilation, airway pressure, peak pressure, respiratory rate, PEEP, oxygen concentration

Pulse oxygen saturation

Blood-gas-analysis,PetCO2

THE RESPIRATORY SYSTEM

Pulse Oxyimetry / Pulse Oxygen Saturation
Pulse oximeters combine the principles of oximetry and plethysmography to noninvasively measure oxygen saturation in arterial blood. Mandatory for any anesthetic including moderate sedation Particularly useful for
Preexisting lung conditions Nature of surgical procedure eg : hiatal hernia repair Requirement of special anesthetic technique eg : one lung ventilation Also useful in arterial pulsation by plethysmography

Depending on a particular patient's oxygenhemoglobin dissociation curve, a 90% saturation may indicate a PaO2 of less than 65 mm Hg

THE RESPIRATORY SYSTEM MONITORING

Capnography (measurement of End Tidal CO2)
Confirm adequate ventilation in all anesthesia procedures specially GA There is no contraindication to this monitoring Capnographs rely on absorption of infra red light by CO2

Anaesthetic gas analysis

Useful for anaesthesia using inhaled gases Measured by infrared absorption anaylysis No contraindication to this monitoring

Oxygen analysis
To measure fiO2 in inhaled gas mixture No contraindications to this measurement Uses either Galvanic cell principle or Paramagenetic analysis

THE RESPIRATORY SYSTEM MONITORING

Spirometry
measure (and therefore manage) airway pressures, volume, and flow, to calculate resistance and compliance, and to display the relationship of these variables as flowvolume or pressurevolume loops Useful for all the patients under GA

DEPTH OF ANAESTHESIA MONITORING

Electroencephalography
Uses simpler 2 channel EEG, by placing electrodes on the forehead The Bispectral Index (BIS) represents a numerical value that has been correlated with the patient's current hypnotic state (see below).

TEMPERATURE
The temperature of patients undergoing general anesthesia should be monitored.
Very brief procedures (eg, less than 15 min) may be an exception to this guideline. No contraindication to this measurement Delirious effects of Hypothermia (Temp less than 36 degree during anaesthesia
Cardiac arrhythmias and ischemia Increased peripheral vascular resistance Left shift of the hemoglobinoxygen saturation curve Reversible coagulopathy (platelet dysfunction) Postoperative protein catabolism and stress response Altered mental status Impaired renal function Decreased drug metabolism Poor wound healing Increased incidence of infection

URINARY OUTPUT
Urinary bladder catheterization is the only reliable method of monitoring urinary output
Utmost care to catheterization as increased chances of infection Useful in CCF, fluid overload, renal failure, shock etc Inadequate urinary output (oliguria) is often arbitrarily defined as urinary output of less than 0.5 mL/kg/h

PERIPHERAL NERVE STIMULATION

For measuring the neuromuscular function of all the patients receiving neuromuscular blocking agents
No contraindications to this monitoring Also to locate peripheral nerves to be blocked by Regional Anaesthesia