Escolar Documentos
Profissional Documentos
Cultura Documentos
during Anesthesia
1
Perioperative period
eoperative evaluation
and preparation anesthesia
Induction of
Maintenance ofRecovery from
anesthesia anesthesia anesthesia
THE CARDIOVASCULAR
SYSTEM
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6
Electrocardiogram (ECG)
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Standard limb lead
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Types of Monitoring
Standard lead II monitoring is used
widely.
However, the CM5 lead configuration has
been advocated for routine intraoperative
monitoring because it reveals more
readily ST segment changes produced by
left ventricular ischaemia.
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Types of Monitoring
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Types of Monitoring
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Electrocardiogram (ECG)
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Position of the Leads
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Electrocardiogram (ECG)
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Monitoring the circulation
However, adequacy of cardiac output and
circulating blood volume may be inferred
indirectly from observation of the following
variables:
1. Peripheral pulse.
2. Arterial oxygen saturation.
3. Peripheral perfusion.
4. Urine production.
5.Arterial pressure.
19
The peripheral pulse
1.Regular palpation of the peripheral
pulse is one of the simplest and most
useful methods of monitoring during
anaesthesia and is mandatory for even
the most minor surgery. (Radial artery)
2.Information may be obtained by
observation of the rate, volume and
rhythm. 20
Pulse
1.Pulse oximetry
oximeters measure the arterial
oxygen saturation and the pulse rate
non-invasively and accurately to within
±2%.
2.A simple probe is attached to a finger ,
an ear lobe, flexed across the nasal
bridge, or wrapped around a child’s digit
and connected to the oximeter.
3.The probe contains two light-emitting
diodes, one for red and one for infrared
light, and a single detector positioned
on the opposite side of the digit or ear
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lobe.
Pulse oximetry----Probe
Disposable finger
probe for pulse
oximeter ,
wrapped around a
23
child‘s digit
Pulse oximetry----
Oximeter
Pulse
oximeter
control and
display
module,
probe is
connected to24
Pulse oximetry
Pathophysiology :
Oxygen is exchanged by diffusion from
higher concentrations to lower
concentrations
Most of the oxygen in the arterial blood is
carried bound to hemoglobin
-97% of total oxygen is normally bound to
hemoglobin (SpO2)
-3% of total oxygen is dissolved in the
plasma (PaO2) 25
Pulse oximetry
Oxygen Saturation :
Percentage of hemoglobin saturated with
oxygen
Normal SpO2 is 95-98%
Suspect cellular perfusion compromise if
SpO2 is less than 95%
-Insure adequate airway
-Provide supplemental oxygen
-Monitor carefully for further changes and
intervene appropriately
26
Pulse oximetry
Oxygen Saturation :
produced .
this way.
present.
38
Systemic arterial
pressure
Auscultation :
1.Auscultation of the Korotkoff sounds is
too cumbersome for routine use during
anaesthesia.
39
Systemic arterial
pressure
Oscillometry (1):
1.The indirect measurement of arterial
pressure using automated oscillometry
has become popular.
2.It free the anesthetist to perform other
tasks.
40
Systemic arterial
pressure
Oscillometry (2):
an automated oscillometer 41
Systemic arterial
pressure
Oscillometry (2):
Multifunctiona
l Monitor
42
Systemic arterial
pressure
Oscillometry (2):
pressure .
Cannula
Manometer
tube
Transducer
Monitor
48
Direct measurement of
1.ABP
The transducer should be zeroed, and
the system should be calibrated.
2. The transducer is connected to the
cannula via a piece of stiff-walled,
saline-filled manometer tube.
3. The pressure signal is displayed as a
waveform on an oscilloscope screen and
systolic, diastolic and mean arterial
pressures displayed digitally. 49
Direct measurement of
ABP indications for arterial
Common
cannulation:
• Major vascular surgery
• Cardiothoracic surgery
• Induced hypotension
• Critically ill and shocked patients
• Surgery for pheochromocytoma
• Neurosurgery
• Necessity for frequent blood gas analysis
50
Direct measurement of
ABP associated with arterial
Morbidity
cannulation :
1. Arterial wall damage and
thrombosis
2. Embolization
3. Disconnection and
haemorrhage
4. Sepsis
5. Tissue necrosis
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Direct measurement of
ABP
Site for Arterial Cannulation:
1. Radial artery:
2. Femoral artery:
3. Brachial artery:
52
1.Central venous
A central venous catheter positioned
pressure
with its tip in the(CVP)
superior (inferior) vena
cava.
2. It provides valuable information
concerning the volume status of the
circulation during anaesthesia.
3. A direct measurement of RV filling
pressure, CVP is good measurement of
LV filling pressure only in the absence of
pulmonary hypertension or mitral 53
Central venous
pressure (CVP)
Internal jugular
vein
External jugular
vein
54
tip in the superior
Central venous
pressure (CVP)
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Femoral Vein
Central venous
pressure
Site for Vein Cannulation:
1. Internal jugular vein
3. Subclavian vein
4. Femoral vein
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Central venous
pressure
1.This route is the least likely to provide
Peripheral arm vein :
correct placement of the catheter
(approximately 40%) .
2.It avoids most of the serious
complications of other routes of
insertion.
3.Thrombophlebitis and sepsis are
common when a peripheral arm vein is
used, particularly if the catheter is left 57
Central venous
pressure
Internal jugular cannulation :
58
Technique for right internal jugular
vein central venous cannulation. 59
Puncture
Procedure
(A) Important surface landmarks are identified.
(B) The course of the internal carotid artery is palpated.
(C) The internal jugular vein is punctured at the apex of
the triangle formed by the two heads of the
sternocleidomastoid muscle with the needle tip directed
toward the ipsilateral nipple.
(D) A guide wire is introduced through the thin-wall
needle into the vein.
(E) The central venous cannula is inserted over the
guide wire, making sure that the proximal end of the
guide wire protrudes beyond the catheter and is
controlled by the operator. See text for greater detail.
60
Central venous
pressureof internal jugular
Complications
cannulation :
1. Air embolism
2. Carotid artery puncture
3. Brachial plexus/phrenic nerve
damage
4. Ectopic placement (numerous
sites)
5. Sepsis
6. Pneumothorax
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Central venous
pressure
Subclavian vein :
1.This approach is more hazardous
than the internal jugular, and less
likely to provide correct catheter
placement.
2.It is the most suitable route if long-
term parenteral feeding.
62
Central venous
pressureof subclavian vein
Complications
cannulation :
1. Pneumothorax
2. Subclavian artery puncture
3. Air embolism
4. Damage to thoracic duct (left
side)
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Measurement should be done at end-
expiration phase.
64
CV
Right atrium
P
65
The junction of mid axillary line and the 4th
intercostal space is the surface markings of the
right atrium, the true zero reference point. 66
Central venous
pressure
1.The normal range
Measurement ofofCVP
values
: is
0~6cmH2O in the spontaneously
breathing patient.
2.In patients receiving IPPV , values of
CVP are approximately 5 cmH2O higher
because of the increased mean
intrathoracic pressure .
3.Trends in measured observations are 67
Central venous
pressure
Increase of CVP :
1. Over hydration
2. Right-sided heart failure
3. Cardiac tamponade
4. Constrictive pericarditis
5. Pulmonary hypertension
6. Tricuspid stenosis and regurgitation
7. stroke volume is high
68
Pulmonary artery pressure
monitoring
PAP—PAC (Swan-
It canGanz)
measure:
2. PA pressure
3. Pulmonary capillary wedged pressure
(PCWP): a balloon at catheter tip
(volume 1.5 ml), when the balloon is
inflated and the vessel is wedged, a
valveless hydrostatic column exists
between the distal port and LA.
69
Pulmonary artery pressure
monitoring
1. CVP: a port for CVP measurement is
located at 30 cm from the tip
2. Cardiac output: measurement of RV
output
3. Blood temperature
4. Derived hemodynamic data
n Mixed Venous O2 saturation (SvO2)
70
The Pulmonary Artery
Catheter
(PA catheter, Swan-Ganz)
Blood temperature CO
Administrat CVP
ion
71
Pulmonary Artery Catheter
1. The proximal lumen. This is situated
approximately 25 cm from the tip and should lie in
the right atrium after final placement of the catheter.
CVP may be measured using this lumen.
2. The distal lumen . Situated at the tip of the
catheter, this lumen lies in a major branch of the
pulmonary artery when the catheter is placed
correctly and is used to measure pulmonary artery
pressure by connecting it to a suitable transducer.
3. The balloon lumen. This lumen permits the
introduction of approximately 1.5 ml of air into the
ballon which surrounds the distal tip of the lumen.
4. Thermistor lumen. A bead thermistor is
situated 4cm from the tip of the catheter and 72
73
1. Distal port – opening is at
the tip (end) of the
catheter .
pulmonary artery pressures (PAP)
systolic (PAS)
diastolic (PAD)
pulmonary capillary wedge pressure (PCWP)
when balloon is inflated PA pressures should
always be monitored continuously
NEVER USE for medication infusion
Can be used for drawing "mixed venous" blood
gas sample
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2. Balloon port
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3. Thermistor and
connector port
the thermistor connector connects the
pulmonary catheter to the cardiac output
computer
thermistor wire within the lumen transmits
blood temperature (core temperature is most
accurate reflection of the body temperature)
used in determining cardiac output
76
4.Proximal port –
approximately 30 cm from
tip of catheter.
also known as CVP port (central venous
solutions or medications
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Location of the catheter
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Waveform during Insertion
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Waveform during Insertion
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Length of Insertion
45 cm: PA
55 cm: wedge
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Derived Hemodynamic
Profiles
Cardiac Output: thermodilution
method; 4~8 L/min
Cardiac Index: CO/BSA; 2.5~4.2
L/min/m2
87
Continuous Cardiac
Output
Continuous Cardiac Output (CCO)
measurement can be achieved by
a electric coil attached on the tip
of PA catheter. It automatically
measures CO every 3 min.
88
Mixed Venous Oxygen
Saturation (SvO2)
Mixed by blood from both SVC
and IVC, sampled at PA
O2 consumption= SaO2-SvO2
∴SvO2=SaO2 - (VO2/Q x Hb x 13)
89
VO2
SvO2=SaO2 - ——————
CO x Hb x 1.3
Causes for decreasing SvO2:
Hypoxemia
Increased Metabolic Rate
Anemia (Blood loss)
Low Cardiac Output
THE RESPIRATORY
SYSTEM
91
Clinical monitoring of
ventilation
Continuous observation should be
made of the following :
1. patient's colour .
2. respiratory rate .
3. adequacy of chest movement .
4. movement of the reservoir bag or
ventilator bellows .
92
Clinical monitoring of
ventilation
Auscultation of both lung fields should
also be performed frequently in order
to detect :
1. equality of air entry .
2. intubation of a bronchus .
3. presence of secretions .
4. occurrence of a pneumothorax .
93
Clinical monitoring of
ventilation
Anaesthetist must check regularly for signs of
respiratory obstruction as evidenced by:
1. tracheal tug .
2. paradoxical abdominal movement .
3. absence of bag deflation .
Some ventilators make a regular noise during
part of the ventilating cycle and this is a
valuable audible monitor.
94
Measurement of airway
pressure
Airway pressure may reflect changes in lung and
chest wall compliance :
Chest wall compliance may be influenced by :
1. degree of muscle paralysis .
2. surgical manipulation .
3. position of the patient .
95
Measurement of airway
pressure
Lung compliance may be influenced by :
1. accumulation of secretions .
2. development of a pneumothorax .
3. position of the patient .
Increased resistance to air flow caused by
bronchospasm or obstruction of the tracheal
tube is reflected by an increased peak airway
pressure.
96
Measurement of airway
pressure
uses of elevation of airway pressure :
1. Kinking of ventilator tubing or tracheal tube.
2. Overinflation of the tracheal tube cuff with
consequent obstruction of the lumen of the tube.
3. Increased secretions.
4. Pneumothorax.
5. Bronchospasm.
6. Inadequate muscle relaxation.
97
Disconnection alarm
When the lungs are ventilated mechanically, the
continuity of the anaesthetic breathing system,
and thus of gas delivery to the patient, should be
monitored using a disconnection alarm
The alarm is activated if the airway pressure
decreases below a preset minimum for a preset
time interval.
98
Disconnection alarm
A large leak, or total disconnection, is indicated if
the alarm is triggered.
In addition, most of these devices sound an alarm
if excessive airway pressures are generated.
A disconnection alarm does not obviate the need
for visual surveillance of the continuity of the
breathing system.
99
End-tidal carbon dioxide
tension (PE'co2) PETCO
PE'co2, correlates well with Paco2, in patients
2
who
have no significant pulmonary disease.
Normal Paco2-PE'co2 gradient is approximately
5mmHg. (Paco2 35-45mmHg, PE'co2 30-40mmHg.)
End-tidal carbon dioxide concentration may be
measured using the principle of infrared absorption
spectrophotometry.
100
End-tidal carbon dioxide
tension (PE'co2) PETCO
2
PE'co2 is useful particularly in the following
circumstances.
b. To provide evidence of correct placement of the
tracheal tube. Capnography is the only method
available which provides rapid and reliable
diagnosis of intubation of the oesophagus.
c. For routine monitoring of the adequacy of
ventilation and the effects of IPPV.
d. To detect rebreathing.
101
End-tidal carbon dioxide
tension (PE'co2) PETCO
• 2
To detect air, fat or pulmonary embolism; a sudden
decrease in PE'co2 occurs as a result of increased
dead space .
n To detect malignant hyperthermia; a progressive
increase in PE'co2, results from increased muscle
metabolism.
n To ensure normocapnia in elderly patients in an
attempt to maintain adequate cerebral perfusion.
n To maintain normal PE'co2 during carotid artery
surgery in order to maintain cerebral perfusion.
102
图 7-5 常见的呼气末二 氧化碳图形
a Normal CO2 waveform
b CO2 drop to zero , Disconnection 。
c CO2 decrease gradually ,
hyperventilation 。
103
d CO increase gradually , hypoventilation 。
PART Ⅲ
OTHER SYSTEM
104
Measurement of
Temperature
General anaesthesia inhibits the patient‘s
ability to maintain body temperature by
depressing the thermoregulatory centre in
the hypothalamus .
Heat loss during anaesthesia is potentiated
by surgery of long duration and exposure of
large surface areas of tissue, e.g. the
abdominal contents during gastrointestinal
operations. 105
Measurement of
Temperature
The use of wet packs and dry inspired
gases compounds the problem.
These sources of heat loss assume
even more importance in children,
especially small babies, whose surface
area is much larger in proportion to
body weight than in the adult.
106
Measurement of
Temperature
easurement to minimize heat loss :
1. The operating room temperature should be as high
as is comfortable for the theater staff.
2. A warming mattress should be placed beneath the
patient.
3. Exposed surfaces should be swaddled with warm
gauze or foil, especially in neonates.
4. All i.v. infusion fluids should be warmed.
5. Inspired gases should be warmed and humidified.
107
Measurement of
TheTemperature
probe may be placed in the
following positions in order to measure
core temperature:
1. The nasopharynx (approximates to brain
temperature) .
2. The oesophagus (approximates to cardiac
temperature).
3. The tympanic membrane (best for core
temperature, but the membrane is delicate and
easily damaged)
4. The rectum.
108