Monitoring in Anesthesia

Dr. Med. Khaled Radaideh

Department of Anesthesiology
Faculty of Medicine
Jordan University of Science and Technology
May 14 1 Dr. Med. Khaled Radaideh, Facharzt
Monitoring in Anesthesia
OBJECTIVES:
1. Guidelines to the practice of anesthesia and patient
monitoring
2. Elements to monitor (Anesthesia depth, Oxygenation,
Ventilation, Circulation, Temperature)
2.1. ECG
2.2. Pulse Oximetry ( Function, Values, Limitations)
2.3. Blood Pressure (methods, indications, limitations, Insertion sites,
values)
2.4. central venous line and pressure (methods, indications,
limitations, Insertion sites and it's advantages, Complications,
values)


May 14 2 Dr. Med. Khaled Radaideh, Facharzt
Monitoring in Anesthesia
OBJECTIVES:
2.5. Capnography and EtCO2 (Uses, Measurement, values, factors
affecting EtCO2)
2.6. Cyanosis
2.7. The oxyhemoglobin dissociation curve (interpretation, causes of
Left and right shifting , key values, O2-Content of Blood)
2.8. Temperature ( Methods, Values, sites)
3. Normal values for a healthy adult undergoing anesthesia



May 14 3 Dr. Med. Khaled Radaideh, Facharzt
Guidelines to the practice of anesthesia and
patient monitoring:
Monitoring in the Past
Visual monitoring of
respiration and
overall clinical
appearance
Finger on pulse
Blood pressure
May 14 4 Dr. Med. Khaled Radaideh, Facharzt
Guidelines to the practice of anesthesia and
patient monitoring:

1. Qualified anesthesia personnel shall be
present in the room throughout the conduct of
all general anesthetics, regional anesthetics
and monitored anesthesia care.
2. A completed pre-anesthetic checklist.
(history, physical exam, lab investigations,
NPO policy)

May 14 5 Dr. Med. Khaled Radaideh, Facharzt
Guidelines to the practice of anesthesia and
patient monitoring:

3. An anesthetic record. ( In general, major
regional anesthesia, or monitored IV conscious
sedation HR and BP should be measured every
5 min. Also time, dose and route of drugs and
fluids should be charted )
4. During all anesthetics, the patients
oxygenation, ventilation, circulation and
temperature shall be continually evaluated.
May 14 6 Dr. Med. Khaled Radaideh, Facharzt
MONITORING
BP
MAP
Temp
RR
O2 sat
HR
May 14 7 Dr. Med. Khaled Radaideh, Facharzt
Elements to Monitor :
Patients with local or regional anesthesia provide verbal
feedback regarding well being.
Onset of general anesthesia signaled by lack of response to
verbal commands, in addition to loss of blink reflex to light
touch.
Inadequate anesthesia can be signaled by : Facial grimacing
or movement of arm or leg. But with muscle relaxants ( fully
paralysis), it can be signaled by : Hypertension, tachycardia,
tearing or sweating.
Excessive anesthesia can be signaled by : Cardiac
depression, bradycardia, and Hypotension. And also may
result in hypoventilation, hypercapnia and hypoxemia when
muscle relaxants is not given.

I. Anesthetic Depth:
May 14 8 Dr. Med. Khaled Radaideh, Facharzt
Elements to Monitor :
Clinically, monitored by patient color ( with adequate
illumination ) and pulse oximetry.
Quantitavely monitored by using oxygen analyzer, equipped
with an audible low oxygen concentration alarm.
III. Temperature
Continuous temperature measurements monitoring is
mandatory if changes in temperature are anticipated or
suspected.


II. Oxygenation:
May 14 9 Dr. Med. Khaled Radaideh, Facharzt
Elements to Monitor :
Clinically, monitored by pulse palpation, heart auscultation
and monitoring intra-arterial pressure or oximetry.
Quantitavely using ECG signals and arterial blood pressure
measurements every 5 min.
V. Ventilation
Clinically, monitored through a correctly positioned
endotracheal tube, also observing chest excursions, reservoir
bag displacement, and breath sounds over both lungs.
Quantitavely by ETCO2 analysis, equipped with an audible
disconnection alarm.
Arterial blood gas analysis for assessing both oxygen and
ventilation.


IV. Circulation:
May 14 10 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Electrocardiogram ECG:

A 3 or 5 lead electrode system is used for
ECG monitoring in the OR.
The 3 lead system has electrodes positioned
on the right arm, left arm and chest position.
( placed in the left anterior axillary line at
the 5
th
interspace, referred to as V5 ). Lead 2
is usually monitored by this system.
The 5 lead system adds a right leg and left
leg electrodes, which allows monitoring v1,
v2, v3, AVR, AVL, AVF and V5.
May 14 11 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Electrocardiogram ECG:

Identification of P waves in lead 2 and its
association with the QRS complex is useful
in distinguishing a sinus rhythm from other
rhythms.
Analysis of ST segment is used as an
indicator of MI. ( Dep.-ischemia / elev.-
infarction )
Over 85% of ischemic events can be detected
by monitoring ST seg. of leads 2 and V5.
May 14 12 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Pulse Oximetry:

Allows beat to beat analysis of oxygenation.
Depends on differences in light absorption between
oxyHb and deoxyHb.
Red and Infra-red light frequencies transmitted
through a translucent portion. (finger-tip or earlobe)
Microprocessors then analyze amount of light
absorbed by the 2 wavelengths, comparing
measured values, then determining concentrations
of oxygenated and deoxygenated forms. (oxy- and
deoxy-)
May 14 13 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Pulse Oximetry:

After all data is processed, oxygen saturation can be
calculated.
Pulse plethysmograph (visual analysis of pulse waveform),
while an audible form (auditory assessment of oxygenation
status).
Pulse oximetry (SpO
2
) measures oxy-, deoxy-, met-, and
carboxyHb.
CO poisoning gives an overestimation of the true O2
saturation(SaO2). E.g. Burn victims.
Inaccurate measurements seen in poor tissue perfusion
(shock or cold extremities), movement, dysrhythmias, or
when electrical interference is present (surgical cautery
unit).


May 14 14 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Blood Pressure BP:


o Methods of BP measurement:
1. Simplest method of BP measurement,
estimating the SBP, is by palpating the return
of arterial pulse as cuff is deflated.
2. auscultation of the Kortokoff sounds on deflation
(providing both SBP and DBP)
Mean Arterial Pressure (MAP) = DBP + 1/3(SBP DBP)


May 14 15 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Blood Pressure BP:

o Methods of BP measurement:
3. Automated non-invasive BP measurements.
METHODOLOGY: a microprocessor controlled oscillometer
(Dinamap) which is used routinely intraoperatively. It
allows automatic inflation of the BP cuff at preset time
intervals, sending readings into a pressure transducer that
digitalizes them. This technique gives rapid, accurate ( 9
mmHg) measurements of SBP, DBP, MAP and HR several
times a minute. LIMITATIONS: Errors occur due to
movements, arrhythmias or BP fluctuations due to
respiration. 3 5 minutes intervals is recommended to
prevent compressive peripheral nerve injury due to repeated
rapid measurements.
May 14 16 Dr. Med. Khaled Radaideh, Facharzt

Monitoring: Blood Pressure BP:

o Methods of BP measurement:
4. Invasive BP measurements.
(Arterial BP):
Indications:
Rapid moment to moment BP changes
Frequent blood sampling
Major surgeries (cardiac, thoracic, vascular)
Circulatory therapies: vasoactive drugs, deliberate
hypotension
Failure of indirect BP: burns, morbid obesity
Sever metabolic abnormalities
Major trauma
The radial artery at the wrist is the most
common site for an arterial catheter.
Alternatives are femoral, brachial and
dorsalis pedis.

May 14 17 Dr. Med. Khaled Radaideh, Facharzt
Central Venous line and Pressure (CVP)
Catheter inserted into the SVC
providing an estimate of the right
atrial and ventricular pressures.
Serial CVP measurements are
more useful than a single value in
order to assess blood volume,
venous tone and right ventricular
performance. HR, BP and CVP
response to a volume infusion
(100 500 ml) is also a useful
test of right ventricular
performance.

May 14 18 Dr. Med. Khaled Radaideh, Facharzt
Central Venous line and Pressure (CVP)
Indications:
CVP monitoring provides Right
Atrial and Right Ventricle pressures
Advanced Cardiopulmonary
disease + major operation
Secure vascular access for drugs
Secure access for fluids + traumatic
pts
Aspiration of entrained air: sitting
craniotomies
Inadequate peripheral IV access
May 14 19 Dr. Med. Khaled Radaideh, Facharzt
Central Venous Line:
PERFORMANCE of Right Internal Jugular Vein
Internal jugular (Int. Jug.) vein lies in
groove between sternal and clavicular
heads of sternocleidomastoid muscle
It is lateral and slightly anterior to
carotid artery
Aseptic technique, head down
Insert needle towards ipsilateral nipple
Seldinger method: 22 G finder; 18 G
needle, guide-wire, scalpel blade,
dilator and catheter
Observe ECG and maintain control of
guide-wire
Ultrasound guidance; Chest-Xray post
insertion.
May 14 20 Dr. Med. Khaled Radaideh, Facharzt
Advantages of Right Int. Jug. vein
Consistent, predictable anatomic location
Readily identifiable landmarks
Short straight course to Superior Vena Cava
Easy access for anesthesiologist at patients
head
High success rate, 90-99%

May 14 21 Dr. Med. Khaled Radaideh, Facharzt
Complications of Central lines (jugular):
Bleeding
Injury to surrounding
structures as carotid artery
Pneumothorax
Arrhythmia
May 14 22 Dr. Med. Khaled Radaideh, Facharzt
Central Venous line Alternative Sites
Subclavian vein:
Easier to insert versus Int. Jug. vein
Better patient comfort v. Int. Jug.
Higher Risk of pneumothorax- 2%
External jugular:
Easy to cannulate if visible.
no risk of pneumothoroax,
high risk or bleeding
20%: cannot access central circulation


May 14 23 Dr. Med. Khaled Radaideh, Facharzt
Central Venous Pressure (CVP )
Monitoring
Reflects pressure at junction of vena cava + RA
CVP is driving force for filling RA + RV
CVP provides estimate of:
Intravascular blood volume
RV preload
Trends in CVP are very useful
Measure at end-expiration
Central Venous Pressure (CVP): 1-10 mmHg

May 14 24 Dr. Med. Khaled Radaideh, Facharzt
Capnography and EtCO2
Capnometry: is the
numerical measurement
of CO
2
concentration
during inspiration and
expiration.

Capnogram: refers to the
continuous display of the
CO
2
concentration
waveform sampled from
the patients airway
during ventilation.
Capnography: is the
continuous monitoring of
a patients capnogram.


May 14 25 Dr. Med. Khaled Radaideh, Facharzt
Capnography and EtCO2
End-tidal CO
2
monitoring is standard for all patients undergoing
GA with mechanical ventilation.
It is an important safety monitor and a valuable monitor of the
patients physiologic status, and it has been an important factor in
reducing anesthesia-related mortality and morbidity.
Co
2
monitoring is considered the best method for verifying
successful intubation and extubation procedures.
It helps in assessment of the adequacy of ventilation and an
indirect estimate of PaCO
2
.
Also it aids in diagnosis of PE, recognition of a partial airway
obstruction, and indirect measurement of airway reactivity
(bronchospasm).
ETCO
2
levels have also been used to predict outcome of
resuscitation.
May 14 26 Dr. Med. Khaled Radaideh, Facharzt
Capnography and EtCO2
Measurement of ETCO2
Sampling the patients respiratory gases near the airway.
Using infra-red gas analysis or mass spectrometry on the
values and concentrations obtained.
Provided that when sampling, inspired CO
2
value should be
near zero. (i.e. ETCO
2
value is a function of CO
2
production,
alveolar ventilation and pulmonary circulation; excluding
inspired CO
2
).
During general anesthesia, with absence of ventilation
perfusion abnormalities, difference between PaCO
2
and
ETCO
2
is about 5 mm Hg (PaCO2 = 40 mmHg, ETCO2 = 35
mmHg)
Increases or decreases in ETCO2 values maybe the result of
increases or decreases in production and elimination.

May 14 27 Dr. Med. Khaled Radaideh, Facharzt
Capnography and EtCO2 Factors affecting ETCO
2
:

Increased ETCO
2
Decreased ETCO
2

Changes in CO
2
Production
Hyperthermia
Sepsis
Thyroid storm
Malignant Hyperthermia
Muscular Activity
Hypothermia
Hypometabolism
Changes in CO
2
Elimination
Hypoventilation
Rebreathing
Partial airway obstruction
Exogenous CO
2
absorption
(laparoscopy)
Hyperventilation
Hypoperfusion
Embolism
Transient increases in ETCO
2
may be noted after: IV bicarbonate
administration, release of extremity tourniquets, or removal of vascular cross-
clamps.
May 14 28 Dr. Med. Khaled Radaideh, Facharzt
Defined as the presence of 5 gm/dL of deoxygenated
hemoglobin (deoxy Hb).
i.e. Hb level = 15 gm/dL, 5 gm/dL release O
2
which leaves 10 gm/dL of oxyhemoglobin
SaO
2
= OxyHb / (OxyHb + DeoxyHb)
= 10 / (10 + 5)
= 66%
SAO
2
of 66% corresponds to PaO
2
of 35mmHg.
In anemic patients the oxygen tension at which cyanosis
is detectable will be even lower.
i.e. Hb level = 10 gm/dL, 5 gm/dL release O
2
SaO
2
= OxyHb / (oxyHb + DeoxyHb)
= 5 / (5 + 5)
= 50%
SAO
2
of 50% corresponds to PaO
2
of only 27 mmHg.
May 14 29 Dr. Med. Khaled Radaideh, Facharzt
The oxyhemoglobin dissociation curve
It is a sigmoid curve that describes the relationship between
oxygen tension (PaO
2
) and binding (SpO
2
).
When PaO
2
is low, the hemoglobin affinity to oxygen falls
rapidly , explaining the sharp sloping .(PaO
2
< 60 mmHg)


May 14 30 Dr. Med. Khaled Radaideh, Facharzt
The oxyhemoglobin dissociation curve
A decrease in PaO
2
of less than 60 mmHg (corresponding to SpO
2

90 %) results in a rapid fall in the oxygenation saturation.
The lowest acceptable O
2
saturation level is 90%.

Left And Right Shifts of the
Oxyhemoglobin Dissociation Curve
Right Left
Decreased affinity of Hb for O
2.
Increased affinity of Hb for O
2.
Causes:
Inc. PCO
2
Hyperthermia
Acidosis
Increased altitude
Increased 2,3-DPG
Sickle Cell Anemia
Inhalational anesthetics
Causes:
Dec. PCO
2
Hypothermia
Alkalosis
Fetal hemoglobin
Decreased 2,3-DPG
Carboxyhemoglobin
Methemoglobin
May 14 31 Dr. Med. Khaled Radaideh, Facharzt
The oxyhemoglobin dissociation curve
Key Values:
a. At PO
2
100 mmHg, Hb 100% saturation.
b. At PO
2
40 mmHg, Hb 75% saturation.
c. At PO
2
27 mmHg, Hb 50% saturation.

Oxygen content of blood:
is the total amount of O
2
carried in blood, including bound and
dissolved O
2
.
O
2 content
= (O
2
-binding capacity * % saturation) + O
2 dissolved

O
2
-binding capacity = maximal amount of O
2
bound to Hb at 100 % sat.

The dissolved O
2
isnt measured by oximetry but by blood gas
analysis.


May 14 32 Dr. Med. Khaled Radaideh, Facharzt
Monitoring Temperature
Objective
aid in maintaining appropriate body temperature
Application
readily available method to continuously monitor
temperature if changes are intended, anticipated or
suspected
Methods
thermostat
temperature sensitive chemical reactions


May 14 33 Dr. Med. Khaled Radaideh, Facharzt
Monitoring Temperature
Potential heat loss or risk of hyperthermia
necessitates continuous temperature
monitoring
Normal heat loss during anesthesia averages
0.5 - 1 C per hour, but usually not more that 2 -
3 C
Temperature below 34C may lead to
significant morbidity
May 14 34 Dr. Med. Khaled Radaideh, Facharzt
Monitoring Temperature
Hypothermia develops when thermoregulation
fails to control balance of metabolic heat
production and environment heat loss
Normal response to heat loss is impaired
during anesthesia
Those at high risk are elderly, burn patients
neonates, spinal cord injuries

May 14 35 Dr. Med. Khaled Radaideh, Facharzt
Monitoring Temperature
Hyperthermia Causes
Malignant hyperthermia
Endogenous pyroxenes (IL1)
Excessive environmental warming
Increases in metabolic rate secondary to:
Thyrotoxicosis
Pheochromocytoma

May 14 36 Dr. Med. Khaled Radaideh, Facharzt
Monitoring Temperature
Monitoring Sites
Tympanic
Esophagus
Rectum
Nasopharynx

May 14 37 Dr. Med. Khaled Radaideh, Facharzt
Normal values for a healthy adult undergoing
anesthesia
Systolic Blood Pressure
Diastolic Blood Pressure
Heart Rate
Respiratory Rate
Oxygen sat. by oximetry
End Tidal Carbon Dioxide tension
Skin appearance
Color
Temperature
Urine Production
SBP
DBP
HR
RR
SpO
2
ETCO
2

85 160
50 95
50 100
8 20
95 100
33 45
warm, dry
pink
36 37.5
>= 0.5
mmHg
mmHg
bpm
rpm
%
mmHg


O
C
ml.kg
-1
.min
-1
Central Venous Pressure
Pulmonary Artery Pressure
Pulmonary Capillary Wedge Pressure
Mixed venous oxygen saturation
Cardiac Output
Mean Arterial Pressure
*MAP = DBP + 1/3 ( SBP DBP )
CVP
PAP (mean)
PCWP
SvO2
CO
MAP
1 10
10 20
5 15
75
4.5 6
80 120

mmHg
mmHg
mmHg
%
1.Min
-1
mmHg
May 14 38 Dr. Med. Khaled Radaideh, Facharzt
Monitoring in Anesthesia
Dr. Med. Khaled Radaideh

THANK YOU

Department of Anesthesiology
Faculty of Medicine
Jordan University of Science and
Technology
May 14 39 Dr. Med. Khaled Radaideh, Facharzt