Monitoring in Anesthesia

พญ.เพชรรัตน์ วิสุทธิเมธีกร
พ.บ., ป. ชั้นสูงสาขาวิสญ
ั ญีวทิ ยา, วว.(วิสญ
ั ญี)
ภาควิชาวิสญั ญีวทิ ยา
วิทยาลัยแพทยศาสตร์กรุ งเทพมหานคร
และวชิรพยาบาล
 Topic module
 1.รู้ วตั ถุประสงค์ และความสำคัญในการเฝ้ าระวัง
 2.รู้ จักข้ อบ่ งชี้และขัอห้ ามในการใช้ เครื่องเฝ้ 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
Depth of Anesthesia Monitor
Echocardiography

Evoked Potential Monitor

Some Specialized Patient Monitors

 Cardiovascular monitoring
 Routine monitoring
 Cardiac activity
 Non-invasive blood pressure ( NIBP )
 Electrocardiography ( ECG )

 Advanced monitoring
 Directarterial 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
หลักการทำงาน
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
 Directarterial 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, Acid-base /
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 อทีเ่ ท่ าไรแล้ วคะ)
 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 monitoring
 Clinical skills
 Monitoring devices
 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 analysis)
 relationship with 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)
Inspiration ETCO2
3
2
1
 Ventilatory monitoring
 Capnometer (End-tidal CO2 analysis)
 Most useful in detection of Esophageal intubation, airway
or circuit disconnection
 Useful in CO2 rebreathing, partial recovery of neuro-
muscular 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 อการแปรผลอย่ าง
ไร
 Cause of Rt-Lt shift of oxygen-hemoglobin
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
 Clinicalskills: 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
 Clinicalskills
 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