MONITORING EQUIPMENT

- Non-invasive Monitoring Equipment

1. Electrocardiogram (ECG)
2. Pulse oximetry
3. Blood Pressure Monitoring
4. Respiratory Rate
5. Level of consciousness

1. ELECTROCARDIOGRAM (ECG)

- The electrocardiogram (ECG) is a graphic representation of the electrical

activity of the heart.
- The position of the positive (recording)electrode in relation to the spread
of the electrical impulse is referred to as the lead. In the critical care unit,
patients are routinely monitored using only one or two of several possible
leads for heart rate and rhythm.
- A single-channel ECG monitor with an oscilloscope, strip recorder, and
digital heart rate display is typically located above the patient at bedside
in the ICU
- Following are the outlines some of the changes in rhythm that would
indicate caution with physical therapy intervention.
o ST change (elevation or depression)
o Onset, increase, or change of foci of premature ventricu-lar
contractions (PVCs)
o Onset of ventricular tachycardia or fibrillation
o Onset of atrial flutter or fibrillation
o Progression of heart block
o Loss of pacer spike

2. PULSE OXIMETRY

- Noninvasive measurement of arterial oxygen saturation (SaO2) by

pulse oximetry provides continuous, safe, and instantaneous
measurement of blood oxygenation.
 - Pulse oximeters compute SaO2 by measuring differences in the visible
and near infrared absorbances of fully oxygenated and deoxygenated
arterial blood. The measurement is expressed as a percentage of
oxygen that is bound to hemoglobin.
- Pulse oximetry is based on two physical principles: (1) the presence of
a pulsatile signal generated by arterial blood, which is relatively
independent of nonpulsatile arterial, venous, and capillary blood and
other tissues; and (2) the fact that oxy-hemoglobin (O2Hb) and
reduced hemoglobin (Hb) have different absorption spectra.
- In ICU patients, a probe is attached to the patient’s finger, forehead, or
earlobe, and the reading is displayed continuously on the monitor.
- The recommendation is to keep the O2 saturation above 90% during
exercise unless otherwise ordered by the physician.
- Inaccuracies in the pulse oximetry readings may be seen in:
• Low perfusion states, such as low cardiac output, vaso-
constriction, and hypothermia, may impair peripheral perfusion and
may make it difficult for a sensor to dis-tinguish a true signal from
background noise
• Anemia
• Abnormal HbHb
• Jaundice
• Arrhythmias, including atrial fibrillation
• Intravascular dyes such as methylene blue
• Dark nail polish
• Fluorescent light
• Motion artifact
• Dark skin pigmentation

3. BLOOD PRESSURE MONITORING

- In critical care units arterial blood pressure is monitored noninvasively by

the oscillometric technique and displayed on the bedside monitor.
- This analysis provides systolic, diastolic, and mean arterial pressure
readings along with heart rate.
- The ICU monitor may be set to assess the pressures at preset times for
updates or can be assessed as needed with the push of the appropriate
button.
 - The systolic blood pressure, or the maximum systolic left ventricular
pressure, reflects the compliance of the large arteries and the total
peripheral resistance. The diastolic blood pressure is the lowest point of
declining pressure resulting from the runoff of blood from the proximal
aorta to the peripheral vessels, and it reflects the velocity of the runoff
and the elasticity of the arterial system.

4. RESPIRATORY RATE

- The respiratory rate of a patient in the ICU is typically monitored as a

waveform produced as a result of the ECG electrodes and is displayed on
the bedside monitor.
- If a patient is mechanically ventilated the number of breaths is also
displayed on the ventilator screen.
- Respiratory rates vary by age and condition of the patient but Normal
adult respiratory rates during quiet breathing are between 12 and 18
breaths per minute.

5. LEVEL OF CONSCIOUSNESS

- A bispectral index sensor (BIS) is used in patients to assess level of

consciousness and thereby monitor sedation levels in the ICU.
- The BIS measures the muscular and cortical activity using a single, small,
flexible sensor that is applied to the forehead and temporal region.
- A value is produced every 15 seconds that ranges from 0 (no cortical
electrical activity and full suppression) to 100 (awake, aware, no
suppression).

- Invasive Monitoring Equipment

1. Arterial Line
2. Central Line
3. Pulmonary Artery Catheter (Swan-Ganz Catheter)
4. Pulmonary Capillary Wedge Pressure
5. Cardiac Output
6. Mixed Venous Oxygen Saturation
1. ARTERIAL LINE

- An arterial line is most commonly inserted through the radial artery

but can also be inserted through the femoral artery. Less commonly, it
can be inserted into the brachial, axillary, ulnar, or dorsalis pedis
arteries.
- It allows for continuous measurement of arterial blood pressure and
allows blood draw access for arterial blood gas measurements.
- The monitoring via the arterial line provides and displays a continuous
measurement of systolic, diastolic, and mean arterial pressures.
- The mean arterial pressure (MAP) is the average pressure tending to
push blood through the circulatory system, and it reflects the tissue
perfusion pressure.
- The acceptable MAP varies between 70- and 110-mm Hg.

2. CENTRAL LINE

- The central line is a central venous catheter inserted most commonly

through the subclavian or jugular vein; however, the femoral access is
also used at times.
- The catheter is placed by a physician and is advanced to rest in the
proximal superior vena cava allowing central venous pressures to be
measured directly.
- It also allows IV access for medication administration and other
procedures.
- The central venous catheter allows for the continuous monitoring of
central venous pressure (CVP) or right atrial pressure (RAP) to assess
cardiac function and intravascular fluid status.
- Additionally, the catheter may be used as a route for medication or
fluid administration, blood sampling, or emergency placement of a
temporary pacemaker.
- For patients requiring a prolonged placement of a central line, a
peripherally inserted central catheter (PICC or PIC line) or a tunnelled
catheter is commonly used for intravenous access.

3. PULMONARY ARTERY CATHETER (SWAN-GANZ CATHETER)

- The pulmonary artery catheter can only be placed by a physician. It is

introduced via a central venous access point (e.g., internal jugular or
 subclavian vein), passing from the venacava into the right atrium, through
the right atrioventricular (tricuspid) valve into the right ventricle, through
the pulmonary valve, and into the pulmonary artery.
- The pulmonary artery catheter permits:
• Direct measurement of RAP,
• Direct measurement of pulmonary arterial pressure (PAP) and
pulmonary capillary wedge pressure (PCWP),
• Indirect measurement of left atrial pressure (LAP), determination
of mixed venous oxygen saturation (SvO2) and cardiac output
(CO),
• Calculation of systemic and pulmonary vascular resistance
(PVR),
• Pacing of the atrium and ventricles.
- When treating patients with a pulmonary arterial catheter, recognition of
the “normalcy” of the potential waveforms is key to deciding whether or
not it is advisable to perform physical therapy.

4. PULMONARY CAPILLARY WEDGE PRESSURE

- Monitoring the PCWP intermittently will provide the information

needed regarding the left atrial and ventricular end-diastolic pressures.
- Reasons to Measure PCWP
• Assess severity of left ventricular failure
• Assess mitral and aortic valve dysfunction
• Assess and treat pulmonary oedema (PCWP >20 mm Hg)
• Assess pulmonary hypertension
• Assess and treat hypovolemic states

5. CARDIAC OUTPUT
- The amount of blood pumped by the heart per unit of time is termed
the cardiac output (Q), and unless an intracardiac shunt is present, the
output of both the right and left ventricles is essentially the same.
- The normal resting is 4 to 8 L/min.
- CO is generally determined clinically by the thermodilution method.
A cold bolus of saline is injected into the right atrium via the proximal
lumen of the pulmonary artery line. The resultant temperature change
is sensed by a thermistor near the tip of the catheter located in the
 pulmonary artery. A temperature–time curve is constructed and
calculated.
- CO measurements do not take into account an individual’s specific
needs with respect to actual body size. For this reason, the CO per
square meter of body surface area, the cardiac index is often reported.
The normal cardiac index for adults is approximately 3.0 L/min/m2.

6. MIXED VENOUS OXYGEN SATURATION

- The amount of oxygen returning to the heart is called the venous oxygen
reserve.
- SvO2 is the direct measurement of the venous oxygen reserve and is
expressed as a percentage of oxygen left combined with Hb after the
tissues have extracted the oxygen needed.
- The value is calculated from a blood sample drawn from the right
ventricle through the pulmonary artery port of the Swan-Ganz catheter.
Under normal conditions, the SvO2 is in the range of 60% to 80%.
- Because venous saturation is decreased only when oxygen supply fails to
meet the demand, the SvO2 can be a sensitive indicator of oxygen supply
or demand status.