[ANESTHESIOLOGY] Monitoring the Anesthetized Patient

Lecturer: Tracy C. Mendoza MD

Transcriber: Patrick Angelo R. Bautista August 2020


References and Legends
nd
• {💻} PPT and {📕} Chapter 3 - Anesthesiology Manual 2 Ed 2.1Oxygenation
• {📖} Morgan & Mikhail’s Clinical Anesthesiology 5 Ed
th
• This is to ensure adequate oxygen concentration in the inspired
• {📌} Transcriber’s Note gas and the blood during all anesthetics.
• Methods to measure oxygenation:
Table of Contents
9 Using an oxygen analyzer and oximeter with low concentration
I. Monitoring the Anesthetized Patient 1
1
alarm limit during general anesthesia.
II. ASA Standards for Basic Anesthetic Monitoring
9 Standard I 1
1
2.2Ventilation
9 Standard II
III. Monitoring of Inspired Gases 2 • To guarantee adequate ventilation of patient during all anesthetics.
9 Oxygen Monitoring 2 • Some methods to confirm sufficient ventilation:
9 Pulse Oximetry 2 9 Qualitative clinical signs (e.g. facial cyanosis, pale nail beds)
IV. Monitoring of Expired Gases 2 9 Continual monitoring with capnography
9 Carbon Dioxide 2 • To maintain ventilation, bag-mask ventilation or endotracheal
V. Blood Pressure Monitoring 2 intubation must be performed to sustain oxygen delivery.
9 Invasive Measurement of Vascular Pressure 3 • Endotracheal intubation requires qualitative identification of
9 Non-invasive Measure of Arterial Blood Pressure 3 carbon dioxide in the expired gas.
9 Effect of BP Cuff Width on BP Readings 3 • A continuous end-tidal carbon dioxide analysis is encouraged
9 Central Venous Pressure 4 during general anesthesia.
9 Pulmonary Artery Monitoring 4
9 Transesophageal Echocardiography 4 2.3 Circulation
VI. Monitoring Neurologic Function 4 • To safeguard patient’s circulatory function during all anesthetics
9 Bispectral Monitoring (BIS) 4 the following methods should be exercised:
VII. Monitoring Neuromuscular Blockade 4 9 ECG should be continuously displayed at all times
9 Peripheral Nerve Stimulator 4 9 Check blood pressure and heart rate
VIII. Samplex 4 9 Plus any of the following:
§ Palpation of a pulse
I. MONITORING THE ANESTHETIZED PATIENT § Auscultation of heart sounds
§ Monitoring intra-arterial pressure tracing
• It is a process by which anesthesiologist recognize and evaluate
§ Ultrasound peripheral pulse monitoring or pulse oximetry.
potential physiologic problems in a timely manner.
• Four essentials feature of monitoring:
9 Observation and Vigilance
2.4 Temperature
9 Instrumentation • This aids in the maintenance of appropriate core body heat during
9 Interpretation of Data all anesthetics.
9 Initiation of Corrective Therapy when indicated • Hypothermia is defined as a body temperature <36°.
• These anesthetic agents affect the body temperature and at the
same time, change in body temperature affect anesthetic drug
II. ASA STANDARDS FOR
actions to the body.
BASIC ANESTHETIC MONITORING • When changes in body temperature are intended or anticipated,
• Emphasize the importance of regular and frequent measurements temperature should be continuously measured and recorded on
• Integration of clinical judgement and experience the anesthesia record.
• The potential for extenuating circumstances that can influence the • Indications for body temperature monitoring:
applicability or accuracy of monitoring systems 9 All patients undergoing general anesthesia except when
duration <15 mins
1. Standard I 9 Unintentional hypothermia during anesthesia

• Qualified anesthesia personnel shall be present in the room

Unintentional Hypothermia During General Anesthesia
throughout the conduct of all general anesthetics, regional
• Occurs when there is no attempt to warm an anesthetized patient.
anesthetics and monitored anesthesia care.
• Phase I – Redistribution
9 The body core temperature decreases by 1-2°C for the first
2. Standard II hour of general anesthesia.
• During all anesthetics, the patient’s oxygenation, ventilation, 9 This phase is due to anesthetic vasodilation (heat
circulation and temperature shall be continually evaluated. redistribution) from warm central compartment to cooler
• Focuses attention on continually evaluating the patient’s: peripheral compartment.
9 Oxygenation • Phase II
9 Ventilation 9 After 3-4 hours under general anesthesia, there is continual
9 Circulation heat loss which cause gradual decline of core body temp.
9 Temperature • Phase III
9 Eventually reaching a steady state equilibrium wherein the
heat loss is the same with the metabolic heat production.

Monitoring of the Anesthetized Patient | 1 of 4



Sites for Temperature Monitoring • Capnograph displays a continuous outline of PCO2 in the airway
a. Tympanic membrane versus time.
9 This area reflects the brain temperature. • Capnometer measures and shows only discrete values of partial
9 Use of tympanic thermometer sensors nowadays prevent it from pressure of CO2 (PCO2) called the end-tidal carbon dioxide
possible trauma and insulation by cerumen in auditory canal. changes in PaCO2.
b. Rectal site • It has evolved as an important physiologic and safety monitor.
9 Not ideal since it has a slow response to changes in body core • CO2 is usually sampled near the endotracheal-gas delivery
temperature. interface.
c. Nasopharyngeal site • Alterations in ventilation, cardiac output, distribution of pulmonary
9 Accurate but poses danger of epistaxis due to instrumentation. blood flow, and metabolic activity influence PECO2 and the
d. Axillary site capnograph display obtained during quantitative expired gas
9 The most common area to measure body temperature. analysis which also uses the Beer Lambert law.
9 However, this has variable correlation between axillary and
core temperature. V. BLOOD PRESSURE MONITORING
e. Esophageal site
9 Most ideal (best of economy, performance and safety) and
• The most important indicator of the adequacy of circulation.
usually incorporated to esophageal stethoscope. • It is an indirect measurement of arterial blood pressure.
rd
9 This is positioned behind the distal 3 of the esophagus or
the level of cardiac region. • The rhythmic contraction of the left ventricle, ejecting blood into
9 This may give falsely low readings if not inserted too deep.
the vascular system, results in pulsatile arterial pressures.
9 Systolic BP – the peak pressure generated during systolic
contraction (in the absence of aortic valve stenosis).
III. MONITORING OF INSPIRED GASES 9 Diastolic BP – the lowest arterial pressure during diastolic
relaxation.
1. Oxygen Monitoring
9 Pulse pressure – the difference between the SBP and DBP.
• Gas machine manufacturers place oxygen sensors on the inspired 9 Mean arterial pressure (MAP) – time-weighted average of
limb of the anesthesia circuit to ensure that hypoxic gas mixtures arterial pressures during a pulse cycle.
are never delivered to patients.

2. Pulse Oximetry
• The standard of care for monitoring O2 during anesthesia. • As a pulse moves peripherally through the arterial tree, wave
• Measures pulse rate and oxygen saturation of hemoglobin on a reflection distorts the pressure waveform, leading to an
noninvasive continuous basis
exaggeration of systolic and pulse pressures.
• Combined technology of plethysmography and spectrophotometry.
9 A plethysmography produces a pulse trace that is helpful in
tracking circulation.
9 Oxygen saturation is determined by spectrophotometry,
which is based on the Beer-Lambert Law.
• Pulse oximetry has the capability for detecting desaturation before
it is clinically-apparent.
• Normal values:
9 Adults: 95% (for those with no lung disease)
9 Children: 96%

How Does a Pulse Oximeter Work?

Figure: Changes in configuration as a waveform moves peripherally.

• The level of the sampling site relative to the heart affects the
It measures 2 types of Hemoglobin by measurement of blood pressure because of the effect of gravity.
Spectrophotometry or Absorbance
of Light:
• Oxygenated or Saturated Hgb
absorbs the infrared band.
• Deoxygenated or Unsaturated
Hgb absorbs the red band.

IV. MONITORING OF EXPIRED GASES

1. Carbon Dioxide
• ETCO2 reflects changes in PaCO2
9 ETCO2 – the amount of carbon dioxide (CO2) in exhaled air,
which assesses ventilation.
9 PaCO2 – partial pressure of CO2 in arterial blood Figure: The difference in blood pressure (mm Hg) at two different sites of
• Capnograph is an essential element in determining the placement measurement equals the height of an interposed column of water (cm
of endotracheal tubes. H2O) multiplied by a conversion factor (1 cm H2O = 0.74 mm Hg).
9 Presence of three consecutive waveforms in the capnograph
confirms that the ET tube traversed the glottic airway opening.

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1. Invasive Measurement of Vascular Pressure
• Permits the opportunity to monitor arterial BP continuously and to
have vascular access for arterial blood sampling.
• This can be done through direct arterial cannulation.
• Indications:
9 Induced current or anticipated hypotension or wide blood
pressure deviations
9 End-organ disease necessitating precise beat-to-beat blood
pressure regulation
9 Need for multiple arterial blood gas measurements
• Contraindications:
9 If possible, catheterization should be avoided in smaller end
arteries with inadequate collateral blood flow or in extremities
where there is a suspicion of preexisting vascular insufficiency.
2. Non-invasive Measurement of Arterial Blood Pressure
2.1 Palpation
• SBP can be determined by:
1) Locating a palpable peripheral pulse
2) Inflating a blood pressure cuff proximal to the pulse until flow is
occluded
3) Releasing cuff pressure by 2 or 3 mm Hg per heartbeat
4) Measuring the cuff pressure at which pulsations are again
palpable.
• Disadvantages:
9 No diastolic/mean arterial blood pressure measurement
9 Possible underestimation of systolic blood pressure
2.2 Doppler Probe
• It has same principle as palpation except substitution of doppler
probe instead of finger.
• Doppler Shift
9 Change / shift in frequency of sound waves as blood flow.
• This is useful in pediatric, obese or trauma patients.
• Some Doppler models can detect both systolic / diastolic pressure.
Figure: A Doppler probe secured over the radial artery will sense red
blood cell movement as long as the BP cuff is below systolic pressure.
2.3 Auscultation
• Inflation of BP cuff in between systolic and diastolic pressure will
cause collapse of underlying artery.
• Korotkoff sounds
9 Produced by a turbulent flow
9 Audible thru stethoscope
• Auscultatory gap
9 Absence of Korotkoff sounds
9 May be encountered among hypertensive patients
2.4Oscillometry
• Arterial pulsations cause oscillation of the inflating cuff.
• Microprocessor interprets measurement thru an algorithm.
9 A microprocessor derives systolic, mean, and diastolic
pressures using an algorithm.
9 Machines that require identical consecutive pulse waves for
measurement confirmation may be unreliable during
arrhythmias (eg, atrial fibrillation).
• In automated BP monitors electronically measure the pressures at
which the oscillation amplitudes changes.
Figure: Oscillometric determination of blood pressure.
2.5Arterial Tonometry
• It measures beat-to-beat arterial BP by sensing pressure required
to partially flatten a superficial artery that is supported by a bony
structure like the radial artery.
• Pressure transducers are applied to the skin overlying the artery
as shown in the figure below.
• Contact stress between the transducer and the skin reflect
intraluminal pressure.
• Disadvantages:
9 Sensitivity to movement artifacts
9 Frequent calibration
Figure: Tonometry is a method of continuous (beat-to-beat) arterial BP
determination. The sensors must be positioned directly over the artery.
3. Effect of BP Cuff Width on BP Readings
• The measurement of the cuff’s bladder should be at least halfway
around the desired extremity.
• The width of the bladder cuff should be 20-50% greater than the
diameter of the extremity.
• Narrower cuff – may overestimate the systolic pressure.
• Wider cuff – may underestimate the systolic pressure.
• The error with a cuff 20% too wide is not as significant as the error
with a cuff 20% too narrow.
• Refer to the figure on the next page:
9 A – narrowest bladder cuff may produce overestimation of
the systolic pressure.
9 B – ideal bladder cuff and will produce accurate results.
9 C – shows a wider bladder cuff that will produce
underestimation of the systolic pressure.
Monitoring of the Anesthetized Patient | 3 of 4


• Train of four (TOF)

9 The most common pattern used to evaluate residual blockade.
9 It has four stimuli at 2 hertz frequency.
9 The TOF ratio (T4/T1) should be above 0.9 (90%) in order to
rule out residual muscle weakness.
• Potential adverse effects of residual neuromuscular blockade in
the immediate postoperative period.
a. Need for tracheal reintubation
b. Impaired oxygenation and ventilation (erroneously attributed to
opioids)
c. Impaired pulmonary function (reduced forced vital capacity and
peak expiratory flow rate)
d. Increased risk of aspiration and pneumonia
e. Pharyngeal dysfunction
f. Delayed discharge from the Post Anesthesia Care Unit (PACU)

Figure: Blood pressure cuff width influences the pressure readings.

Three cuffs, all inflated to the same pressure, are shown. The narrowest
cuff (A) will require more pressure, and the widest cuff (C) less pressure, to
occlude the brachial artery for determination of systolic pressure.
(A) Narrowest – Overestimation
(B) Ideal – Accurate
(C) Widest – Underestimation

4. Central Venous Pressure (CVP)

• Essentially equivalent to right atrial pressures
• Serve as a reflection of right ventricular preload.
• Reflects the:
9 Amount of blood returning to the heart
9 Ability of the heart to pump the blood into the arterial system
Figure: Peripheral Nerve Stimulator attached to anesthetized
patient under neuromuscular block.
5. Pulmonary Artery Monitoring
• A flow-directed device described as a balloon flotation-
pulmonary artery catheter.
VIII. SAMPLEX
• It is a major advance in hemodynamic monitoring, and it has There are only 3 questions on my samplex regarding this topic. LOL.
become an important tool in the quantitative assessment of Still a lot of possible questions. Study well!
cardiopulmonary function.
1. Which of the following monitors is under the principle of Oscillometry?
A. Capnogram C. Electrocardiogram
6. Transesophageal Echocardiography B. Pulse oximeter D. Blood pressure monitoring
• Accurate estimates of left ventricular preload.
2. Which of the following monitors is under the principle of Beer-
• Estimates intra-cardiac filling and contractility.
Lamberts Law?
• Estimates ejection fraction.
A. Capnogram C. Electrocardiogram
B. Pulse oximeter D. Blood pressure monitoring
VI. MONITORING NEUROLOGIC FUNCTION 3. In monitoring thermoregulation during general anesthesia, which of the
1. Bispectral Monitoring (BIS) following location is best to place probe to access body core temp?
A. Oral C. Distal esophagus
• The BIS monitor determines the depth of general anesthesia. B. Rectal D. Tympanic membrane
• It has a sensor which is placed on the patient’s forehead to pick up
electrical signals from the cerebral cortex and displays it in the 📌 No proofreading. Use at your own risk.
digital signal converter. Use Samplex questions only as your guide.
• BIS values varies from 0 to 100 Good luck!
9 0 means ‘deep sleep’
9 100 means ‘awake’
• Ideal value range to safely perform surgery is between 40-60.

VII. MONITORING NEUROMUSCULAR BLOCKADE

1. Peripheral Nerve Stimulator
• A recommendation for standards of monitoring during anesthesia
and recovery” studied by the Association of Anesthetists of Great
Britain and Ireland (AAGBI) requires that “a peripheral nerve
stimulator must be utilize whenever neuromuscular blocking
drugs are administered.”
• This device delivers an electrical stimulus to a peripheral nerve,
most commonly the ulnar nerve.
• The expected outcome is twitching of the innervated thumb and
the presence or absence of muscle weakness is evaluated by
decreasing muscle twitching with repetitive nerve stimulus.

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