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MONITORING
• Resusitasi
• Terapi suportif
• Monitoring ketat
Preoperative management
• Previous adverse responses related • Central Nervous System
to anesthesia • Cerebrovascular insufficiency
• Seizures
• Allergic Reactions
• Sleep apnea
Prolonged skeletal muscle paralysis
•
• Delayed awakening
• Cardiovascular System
• Nausea and vomiting • Exercise Tolerance
• Adverse responses in relatives • Angina
• Prior MI
• HTN
• Claudication
• Lungs • Kidneys
• Exercise Tolerance • Nocturia
• Dyspnea and Orthopnea • Pyuria
• Cough and Sputum Production
• Cigarette consumption
• Pneumonia • Skeletal and Muscular Systems
• Recent upper resp. tract infection • Arthritis
• Osteoporosis
• Liver • Weakness
• Alcohol Consumption
• Hepatitis
• Endocrine System • Reproductive System
• Diabetes mellitus • Menstrual History
• Thyroid gland dysfunction • STD’s
• Adrenal gland dysfunction
• Dentition
• Coagulation • Dentures
• Bleeding tendency • Caps
• Easy bruising
• Hereditary coagulopathies
Intraoperative monitoring:
Introduction
The most primitive method of monitoring the patient 25
years ago was continuous palpation of the radial
pulsations throughout the operation!!
What is the value of knowing this?
To understand & appreciate the value of clinical
monitoring.
RULE: your clinical judgement/assessment is much
BETTER & much more VALUABLE than the digital
monitor.
To appreciate that modern monitors have made life
much easier for us. They are present to make
monitoring easier for us NOT to be omitted or
ignored.
Intraoperative monitoring:
Introduction
Why do we need intraoperative monitoring???
• To maintain the normal physiology & homeostasis throughout
anesthesia and surgery: induction, maintenance & recovery as
much as possible. To ensure the well being of the pt.
• Surgery is a very stressful condition → severe sympathetic
stimulation, HTN, tachycardia, arrhythmias.
• Most drugs used for general & regional anesthesia cause
hemodynamic instability, myocardial depression, hypotension
& arrhythmias.
• Under GA the pt may be hypo or hyperventilated and may
develop hypothermia.
• Blood loss → anemia, hypotension. So it is necessary to
recognise when need of blood transfusion (transfusion point).
Intraoperative monitoring:
Introduction
The FOUR BASIC Monitors:
• We are NOT authorised to start a surgery in the
absence of any of these monitors:
• ECG.
• SpO2: arterial O2 saturation.
• Blood Pressure: NIBP (non-invasive), IBP (invasive).
• ± [Capnography].
• The most critical 2 times during anesthesia are:
INDUCTION - RECOVERY.
• Exactly like “flying a plane” induction (= take off) &
recovery (= landing). The aim is to achieve a smooth
induction & a smooth recovery & a smooth
intraoperative course.
(1) ECG
Intraoperative monitoring: (1) ECG
Value:
Heart rate.
Rhythm (arrhythmias) usually best identified from lead II.
Ischemic changes & ST segment analysis.
Timing of ECG monitoring: Throughout the surgery: before
induction until after extubation & recovery.
Types & connections of ECG cables:
3-leads: Red=Right YeLLow=Left Black=Apex (can
read leads: I, II, III)
5-leads: Red=Right YeLLow=Left Black=under red
Green=under yellow White=central (can read any of
the 12 leads: I, II, III, avR, avL, avF, V1-V6).
Intraoperative monitoring: (1) ECG
• RULES:
• QRS beep ON must be heard at all times. NO
silent monitors.
• Remember that your clinical judgement is
much more superior to the monitor. Check
peripheral pulsations.
• Cautery → artefacts & fallacies in ECG (noise/
electrical interference) → check radial
(peripheral) pulsations.
• Arrythmias → check radial (peripheral)
pulsations.
(2) SpO2
Intraoperative monitoring: (2) SpO2
It is the most important monitor. It gives a LOT of
information about the pt.
Definition: % of oxy-Hb / oxy + deoxy-Hb.
Timing of SpO2 monitoring: throughout the surgery:
before induction till after extubation & recovery. It is
the LAST monitor to be removed off the pt before the pt
is transferred outside the operating room to recovery
room. SpO2 monitoring should be continued in recovery
room.
Waveform of pulse oximeter = plethysmography
(arterial waveform). It indicates that the pulse oximeter
is reading the arterial O2 saturation. Without the
waveform pulse oximeter readings are unreliable &
incorrect.
Intraoperative monitoring: (2) SpO2
Value:
SpO2: arterial O2 saturation (oxygenation of the pt).
HR.
Peripheral perfusion status (loss of waveform in
hypoperfusion states: hypotension & cold extremeties).
Gives an idea about the rhythm from the plethysmography
wave (arterial waveform). (Cannot identify the type of
arrhythmia but can recognize if irregularity is present).
Cardiac arrest.
Position of ETT.
Respiratory System.
CVS & Hemodynamic Monitoring.
CNS: Awareness.
Temperature.
Monitoring after Extubation & Recovery.
(A) Correct Position of ETT
(B) Respiratory Monitoring
Clinical monitoring:
Colour: cyanosis: nails, lips, palms, conjunctiva.
Chest rise & fall (inflation).
Vapour in ETT (absent in ventilators with humdifiers/if
filter is used).
Airway pressure.
Ventilator bellows (return to full inflation during
expiratory phase).
Ventilator sound: during resp cycle. Abnormal sounds eg.
leakage, disconnection, high airway pressure, alarms.
Pin Safety System Index dan kode
warna
Pneumatic ventilator
Vaporizer
(B) Respiratory Monitoring
• N.B. Various alarms by the ventilator:
NEVER ignore an alarm by the ventilator!
• Low airway pressure: leakage, disconnection.
• High airway pressure: kink, biting of the tube,
bronchospasm, slipped → esophagus.
• Low expired tidal volume: leakage.
• Apnea alarm: disconnection.
• O2 sensor failure: (unfortunately common in many of
our ventilators).
• Flow sensor failure: (unfortunately common in many of
our ventilators).
(B) Respiratory Monitoring
Respiratory Monitors:
O2 Saturation.
Capnography EtCO2.
Airway pressure.
ABG samples.
(C) CVS Hemodynamic Monitoring
Clinical monitoring:
• Colour: pallor (lips, tongue, nails) = anemia, shock.
• Palpate peripheral pulsations every 10 minutes (Radial A,
Dorsalis pedis A, Superficial temporal A).
• Capillary refilling time: compress nail bed until it is
blanched. After release of pressure refilling should occur
within 2 seconds. If ˃ 5 seconds = poor peripheral
perfusion/circulation.
• UOP:
• Values: it is an indicator of: 1) good hydration 2) good tissue (renal)
perfusion 3) good renal function. [Urine is the champagne of
anesthetists and urologists!!].
• Indications: 1) lengthy surgery ˃ 4 hrs 2) major surgery with major
blood loss 3) C-section: to monitor injury to the bladder or ureter.
• Normal: 0.5-1 ml/kg/hr.
• When the catheter is inserted u must always note the baseline urine
volume at the start of operation.
(C) CVS Hemodynamic Monitoring
Management of oliguria or anuria:
• Check that the line is not kinked or disconnected.
• Palpate the urinary bladder (suprapubic fullness), or
ask the surgeon to palpate it.
• Raise BP (MAP ˃ 80 mmHg): renal perfusion.
• IV fluid challenge.
• Diuretics.
• N.B. Sometimes trendlenberg position (head down)
causes ↓ UOP. Reversal of this posi on results in
immediate flow of urine.
(D) CNS: Awareness
Clinical monitoring:
Signs of pt awareness:
Movement, grimacing (facial expression).
Pupils dilated.
Lacrimation.
Tachycardia.
HTN.
Sweating: is always an alarming/warning sign. Causes:
Awareness.
Hypoglycemia.
Hypercapnia.
Thyroid storm (thyrotoxic crisis).
Fever.
Always check the concentration of ur vaporizer & make sure
that ur vaporizer is not empty
Bispectral Index (BIS)
IOC
(E) Temperature Monitoring
• Clinical monitoring: ur hands.
• Monitors: temperature probe: nasopharyngeal,
esophageal.
• AVOID hypothermia < 36oC. Why? & How?
• Especially in pediatrics & geriatrics (extremes of
age).
• Why is it necessary to avoid hypothermia?
(complications of hypothermia):
• Cardiac arrhythmias: VT & cardiac arrest.
• Myocardial depression.
• Delayed recovery (delays drug metabolism).
• Delayed enzymatic drug metabolism.
• Metabolic acidosis ( ssue hypoperfusion → anerobic glycolysis
→ lac c acidosis) & hyperkalemia.
• Coagulopathy.
(F) Monitoring After Extubation &
Recovery
• After extubation: immediately fit the face mask on the pt
(with a slight chin lift) and observe the breathing bag:
• Good regular breathing with adequate tidal volume
• No transmission to the bag → ( respiratory obstruction or apnea )
• BP: within 20% of baseline.
• SpO2: ˃ 92%
• Breathing: regular, adequate tidal volume.
• Muscle power: sustained head elevation for 5 seconds, good
hand grip, tongue protrusion.
• Level of consciousness: fully conscious = 1) obeying orders, 2)
eye opening, 3) purposeful movement.
• MOST IMP: Pt MUST be able to protect his own airway.
To Summarize:
“How do I monitor the patient in OR?”
The 4 basic monitors displayed on the screen:
1) ECG.
2) BP.
3) SpO2.
4) ± Capnogram (EtCO2).
Normal target values for an adult under GA: