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Monitoring

during Anesthesia

1
Perioperative period

preoperation operation postoperation

eoperative evaluation
and preparation anesthesia

Induction of
Maintenance ofRecovery from
anesthesia anesthesia anesthesia

Monitoring during anesthesia 2


 The word monitor is derived from the Latin
verb monere — to warn. The purpose of a
monitoring device is to measure a
physiological variable and to indicate
trends of change, thus enabling
appropriate therapeutic action to be taken.
 It is essential to ensure that all monitoring
equipment is maintained correctly and
that it functions accurately, so that the
information which it provides is reliable .
 The user should understand the basic
principles on which monitoring equipment
is based and be able to interpret the
information provided. 3
Monitoring during
Anesthesia
 Cardiovascular System
 Respiratory system
 Body Temperature: geriatric, pediatric
 Neuromuscular Junction: muscular
relaxant
 Nervous System: depth of anesthesia
 Coagulation System: cardiothoracic
surgery
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PART Ⅰ

THE CARDIOVASCULAR
SYSTEM

5
6
Electrocardiogram (ECG)

 ECG monitors have become increasingly


reliable and less subject to interference.
 As the technique is non-invasive, simple
and accurate, it is now regarded as
mandatory in the UK that the ECG should
be monitored in all patients undergoing
anaesthesia, no matter how minor the
surgery procedure.
7
Electrocardiogram (ECG)
One of the standardized monitors during
any form of anesthesia.
For detection and diagnosis of
Dysrhythmias: Tachycardia, Bradycardia,
VF
Conduction defects: AVB ( auriculo-
ventricular block )
Cardiac ischemia: CAD

Electrolyte disturbance: Potassium,


Magnesium hyperkalemia, hypokalemia
8
Types of Monitoring

 Five-electrode system: one on


each limb and one precordial lead
(V5, along the anterior axillary line
in the fifth intercostal space  for
detection of anterior ischemia).
9
Precordial lead

Posterior axillary line


Midclavicular line

Anterior axillary line Midaxillary line

10
Standard limb lead

11
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.
12
Types of Monitoring

13
Types of Monitoring

Right arm lead over


manubrium sterni

14
Electrocardiogram (ECG)

Kaplan et al. (Anesthesiology, 1976):


90% of intraoperative cardiac ischemia will
be detected by multiple ECG, especially V5.
At least two leads should be simultaneously
showed on the monitor.

15
Position of the Leads

 The four limb leads should be placed on


the back of shoulders and hips, where
they will disturb the operative field the
least.
 Every lead should be fixed and protected
with tape to prevent dislodgement of
leads during operation.

16
Electrocardiogram (ECG)

 It is important to appreciate that the ECG


is an index only of electrical activity. It is
possible for a normal electrical waveform
to exist in the presence of a negligible
cardiac output.
 Consequently, information from the ECG
should be used in conjunction with data
acquired from monitoring of perfusion .
17
Monitoring the circulation
 Maintenance of perfusion of vital organs is one
of the principal tasks of the anaesthetist during
surgery. Adequate perfusion is dependent on
adequate venous return to the heart, cardiac
performance and arterial pressure.
 Direct measurements of cardiac output and
blood volume are difficult during anaesthesia
and require invasive procedures which are
inappropriate in many situations.

18
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
21
lobe.
Pulse oximetry----Probe

Finger probe for


pulse oximeter ,
attached to a 22
finger
Pulse oximetry----
Probe

Disposable finger
probe for pulse
oximeter ,
wrapped around a
23
child‘s digit
Pulse oximetry----
Oximeter

Waveform S Pulse rate


pO2

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 :

 Suspect severe cellular perfusion


compromise when SpO2 is less than 90%
– Insure airway and provide positive
ventilations if necessary.
– Administer high flow oxygen.
– Head injured patients, SpO2 should
never drop below 90%.
27
Pulse oximetry
SpO2 and PaO2:

 SpO2 indicates the oxygen bound to


hemoglobin
-Closely corresponds to SaO2 measured in
laboratory tests
-SpO2 indicates the saturation was
obtained with non-invasive oximetry
 PaO2 indicates the oxygen dissolved in the
plasma
28
-Measured in ABGs (artery blood gases)
Pulse oximetry
SpO2 and PaO2:

 Normal PaO2 is 80-100 mmHg


– Normally
 80-100 mm Hg corresponds to 95-100%
SpO2
 60 mm Hg corresponds to 90% SpO2
 40 mm Hg corresponds to 75% SpO2
29
Pulse oximetry
Advantages:
1.Pulse oximeters are simple to use, non-
invasive and require no warm-up time.
2.Provide an overall assessment of the
integrity of all the systems involved in
delivering oxygen to the tissues :
Oxygen supply, intake and delivery.
3.unaffected by pigmented skin 30
Pulse oximetry
Disadvantages:
1.Pulse oximeters read inaccurately in the
presence of carboxyhemoglobin,
methemoglobin or other pigments, e.g.
bilirubin .
2.Some models are inaccurate in the
presence of poor tissue perfusion or
excessive vasoconstriction. 31
Peripheral perfusion
1.It is assessed most usefully by
observation of the patient's extremities.
2.Warm, dry, pink skin indicates adequate
peripheral perfusion; cold, white
peripheries the converse .
3.This is particularly true in children, in
whom cool peripheries usually indicate
hypovolaemia.
32
Peripheral
1.The perfusion
core-peripheral temperature
gradient is a useful index of adequacy
of peripheral perfusion.
2.One temperature probe is placed
centrally (e.g. in the nasopharynx) and
the other peripherally (e.g. on the great
toe) .
3.The temperature gradient increases
with vasoconstriction and low cardiac
output, and decreases gradually as
vasodilation occurs with increasing limb
blood flow consequent upon increasing
33
cardiac output.
Urine output
1.Adequacy of renal perfusion may be

inferred from the volume of urine

produced .

2.The kidney is the only organ whose

function may be monitored directly in

this way.

3.Adequate production of urine implies

that perfusion of other vital organs is


34
Urine output
1.Accurate measurement of urine
volumes with a urimeter is particularly
indicated in the following situations:

1. Major vascular 4. Critically ill/shocked


surgery. patients .
2. Cardiac surgery. 5. Massive fluid or blood
loss .
3. Major trauma. 6. Surgery in the jaundiced
patient.
35
aim is to achieve a urine output of 0.5~1ml.kg .h-1. -1
Systemic arterial
pressure
1. Measurement of arterial pressure may
be classified
into indirect or direct methods.
Indirect Direct
Palpation Intra-arterial manometry
Auscultation IABP CV PAC
Oscillometry P
Doppler ultrasound
LAP, LVP, PAP, PCWP, CO, SVO2
1. Measurement of arterial pressure is
mandatory
during anaesthesia in all patients .
36
3. It is an indirect method of estimating
Systemic
adequacy of arterial
pressure
cardiac output, because:
Blood pressure = CO × peripheral
resistance
4. In conjunction with estimation of
peripheral
perfusion, it is an invaluable
measurement.
6. Indirect, non-invasive methods of
measurement 37
Systemic arterial
pressure
Palpation :
• Palpation of the radial pulse as the

sphygmoma-nometer cuff is deflated is

a simple method of measuring systolic

pressure, but is inaccurate at low

pressures or when vasoconstriction is

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):

1.These devices incorporate:


a.A microprocessor which controls the
inflation and deflation sequence.
b.An air pump inflates the cuff; a bleed-
valve then deflates it in discrete
decrements of pressure.
c. A pressure transducer records the
pressure signals, which in turn are 43
Cuff Size

 Too small cuff will result in high


blood pressure reading.
 A loosely applied cuff will also
produce a reading higher than it
should be.
 Too large cuff will severely
44
Cuff Size

from Barbara Bates: A Guide to Physical


Examination 45
Systemic arterial
pressure
Oscillometry (3):
Disadvantages:
a. Inaccurate when SBP less than 60mmHg

b. Unable to follow rapid swings in arterial

pressure .

c. Under-reading occurred at high systolic


46
pressures
Direct measurement of
ABP
1. It is achieved by attaching a
transducer to an intra-arterial cannula
inserted into a peripheral artery.
2. It is an invasive procedure which
carries potential morbidity.
3. The method is only justified when
rapid changes in arterial pressure are
anticipated during anaesthesia.
47
IABP system

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
51
Direct measurement of
ABP
Site for Arterial Cannulation:

1. Radial artery:

2. Femoral artery:

3. Brachial artery:

4. Dorsalis pedis 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)

55
Femoral Vein
Central venous
pressure
Site for Vein Cannulation:
1. Internal jugular vein

2. External jugular vein

3. Subclavian vein

4. Femoral vein

5.Peripheral arm vein

56
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 :

This route is associated with the


highest incidence of correct
catheter placement (approximately
90%).

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
61
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)
63
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

PAP, PCWP, SvO2

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

measures the temperature of blood at this site.


Pulmonary Artery
Catheter
 PA Port: YELLOW
 CVP Port: BLUE
 PA balloon Port: RED

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

74
2. Balloon port

 located about < 1 cm from tip of the catheter


 the balloon is inflated with proximately 0.8 to 1.5 cc
of air
 do not inflate with liquid---- always inflate with air
 when deflated, turn stopcock to off position and
leave syringe connect to port

75
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

pressure) lies in the right atrium and

measures CVP can be used for infusion of IV

solutions or medications

77
78
79
Location of the catheter

80
Waveform during Insertion

81
82
Waveform during Insertion

83
Length of Insertion

Usual conditions (just for ease to


memorize)
 35 cm: RV

 45 cm: PA

 55 cm: wedge

 But the actual length may vary


greatly between patients!
84
Hemodynamic
Measurements--Normal
Range
 RA pressure: 2~6 mmHg
 RV pressure: systolic 15~25 mmHg;
diastolic 0~4 mmHg
 PA pressure: systolic 15~25 mmHg;
diastolic 8~16 mmHg
 Mean PAP: 10~20 mmHg
 Pulmonary Capillary Wedge Pressure
(PCWP): 6~12 mmHg
85
Derived Hemodynamic
Profiles
 Systemic Vascular Resistance
(SVR): 80 x (MAP-CVP)/CO;
800~1200 dyne-sec-cm-5

 Pulmonary Vascular Resistance


(PVR): 80 x (PAP-PCWP)/CO;
20~130 dyne-sec-cm-5

86
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

→ when the former three


parameter is constant, SvO2
reflex CO. 90
PART Ⅱ

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

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