Transcript Monitoring in Anesthesia

Monitoring in Anesthesia
พญ.เพชรรัตน์ วิสุทธิเมธีกร
พ.บ., ป. ชั้นสูงสาขาวิสญ
ั ญีวทิ ยา, วว.(วิสญ
ั ญี)
ภาควิชาวิสญ
ั ญีวทิ ยา
วิทยาลัยแพทยศาสตร์กรุ งเทพมหานคร
และวชิรพยาบาล
Topic module
1.รู้ วตั ถุประสงค์ และความสาคัญในการเฝ้ าระวัง
 2.รู้ จักข้ อบ่ งชี้และขัอห้ ามในการใช้ เครื่ องเฝ้ าระวัง
 3.สามารถใช้ และแปรผลค่ าทีไ่ ด้ จากเครื่องเฝ้ าระวัง
( NIBP , SpO2 , ECG , ET-CO2 )

Contents
 Introduction
What
is monitoring?
Which, Why and How to monitor?
 Level of monitoring
 Standards for basic intraoperative
monitoring ( ASA)
 Systematic monitoring
 Conclusion
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 (การเฝ้ าระวัง, การเตือนภัย)
 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
BP or HR)
Things
you observe (e.g. observation of pupils)
Planning
to avoid trouble (e.g. planning induction of
anesthesia or planning extubation)
Inferring
diagnoses (e.g. unilateral air entry may mean
endobronchial intubation)
Planning
to get out of trouble (e.g. differential diagnosis
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
Standard II
 During
all anesthetics, the patient’s respiratory
(ventilation, oxygenation), circulation and temperature
shall be continually evaluated
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
Not 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 and
neurosurgical events

( increased intracranial pressure leads to
hypertension and bradycardia )
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
การบ้ าน ECG
1. การติด lead II, modified V5
2. การแปรผล สาเหตุ การรักษา
-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

การบ้ าน
หลักการทางาน
หลักการเลือกขนาด
ค่ าทีไ่ ด้ ค่ าใดถูกต้ องและเชื่อถือได้ มากทีส่ ุ ด
สถานะการณ์ ใดรบกวนการวัดและรบกวนอย่ างไร
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: Raynaud’s
phenomenon, DM
Risks of thrombosis: hyperlipidemia, previous
brachial artery cannulation
 Modified Allen’s test
??? ( การบ้ านข้ อที่เท่ าไรแล้วคะ)
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
skills
 Monitoring devices
monitoring
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 :
normal curve
 1.
Dead space air (no CO2)
 2. Mixed bronchus & alveolus air (CO2 upstroke)
 3. Alveolus air (CO2 plateau)
1
2
3
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
การบ้ าน (เขียน waveform of ET-CO2 และสาเหตุ)
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
การบ้ าน
 Wave form
Pulse oximeter
 Pulse oximeter artifacts กระทบต่ อการแปรผล
อย่ างไร
 Cause
of Rt-Lt shift of oxygenhemoglobin dissociation curve
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
การบ้ านกีข่ ้ อแล้ วคะ
มีเครื่องมือเยอะจัง
ไม่ ได้ อย่ า out ต้ องรู้ NIBP,ECG,ET-CO2,SpO2