Anes - Intraoperative Management

DR. RITCHE AGCAOILI SEPT.
18, 2020
 Stage I- Analgesia (loss of pain sensation)

 Stage II- Excitement (combative behavior)
TOPIC OUTLINE
 Stage III- Surgical Anesthesia
I. Intraoperative Management
 Stage IV- Medullary Paralysis (paralysis of
II. Stage of Anesthesia
III. Oxygenation respiratory centers
IV. Ventilation
Four main stages are recognized based upon:
LEGEND  Body movements
Must Know Book Doctor’s Lec Lecturio  Respiratory rhythm
 Oculomotor reflexes
 Muscle Tone
Stage 1: Amnesia and Analgesia

Intraoperative Monitoring
 Conscious and rational with diminished pain
perception
Monitoring
 From induction of anesthetic to loss of
 designed to collect data that reflect the patient’s consciousness
ongoing physiologic conditions and any  Patient is able to:
responses o Open eyes on command
 “monere”- warning o Breathe normally
 interpret available clinical data to help recognize o Maintain protective reflexes
o Tolerate mild painful stimuli
present or future mishaps or unfavorable system
condition Stage 2: Delirium
Monitoring Anesthetized Patients
 Anesthetic agents are cardiopulmonary  From loss of consciousness to appearance of
depressants regular breathing and loss of eyelid reflex
 Patient demonstrates:
 Homeostasis - goal
o Movement of limbs and tense struggle
 Response to interventions o Irregular breathing
 Proper function of anesthetic equipment o Breath holding
Patient monitoring involves continuous monitoring of: o Dilated pupils but remains reactive to
 Things you measure (Physiologic parameters) light
 Things you observe (e.g., pupils) Stage 3: Surgical Anesthesia
 Planning to avoid trouble (induction of
anesthesia or extubation)  From resumption of breathing to cessation of
 Inferring diagnosis (unilateral air entry --> respiration
endobronchial intubation)  No response to surgical incision
Planning to get out of trouble (differentials and algorithm  Surgery occurs during one of four levels of stage
3:
formulation)
Stage 4: Anesthetic Overdose
Intraoperative Anesthesia
 Action must be taken to decrease anesthetic or
Induction cardiac arrest may occur
A. Maintenance of Anesthesia  Patient exhibits:
B. Recovery o Cessation of spontaneous respiration
C. Depth of Anesthesia o Severe bradycardia and hypotension
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Marco, Mausisa, Najito, Picones, Villones
DR. RITCHE AGCAOILI SEPT. 18, 2020
o Cardiac arrest 1. Amount of light absorbed is proportional to the

o Absent reflexes concentration of the light absorbing substance
(Beers Law)
Level 1  Absence of pupillary reaction to light
 Disappearance of eyelid reflex
 Regular respiration
 Abolished vomiting reflex
Level 2  Fixed eyes at midline
 Decreased activity of intercostal and
thoracic muscles during respiration
 Disappearance of laryngospasm reflex
 General muscle tone becomes more
flaccid 2. Amount of light absorbed is proportional to the
Level 3  Decreased intercostal muscle activity to
length of the path that the light has to travel in
point of cessation
the absorbing substance (Lambert’s Law)
 Respiration from diaphragm
 Pupils become more dilated
Level 4  Intercostal paralysis
 Cessation of spontaneous respiration
 Pupils become very dilated
Oxygenation
Measured by: Both arteries have the same concentration but the
 Adequate illumination of patient’s color artery on right is wider than the one on the left
 Pulse oximetry Oxyhemoglobin absorbs more infrared light
o measures oxygen saturation 3. (950nm) than red light. Deoxyhemoglobin absorbs
o based on application of Beers- more red light (650nm) than infrared light
Lambert Law MNEMONIC: SeXy DARLing
o illuminates the tissue sample with two At SiX hundred … wavelength,
wavelengths of light Deoxyhb Absorbs Red Light
 660-nm red light
(oxyhemoglobin), and 940-nm Factors That Influence the Accuracy of Pulse Oximetry:
infrared light 1. Falsely High SpO2
(deoxyhemoglobin)  Presence of abnormal hemoglobin
o Common in use  COHgb – absorbed in red light ∴ high
Oxygen saturation levels are detected using oximeter
o Carbon monoxide poisoning –
 percentage of available hemoglobin that high SpO2 upon pulse oximetry,
carries oxygen pinkish color, red tongue,
 Examples: hypoxemic
o If there are 16 hemoglobin units and  MetHgb – absorbed in both infrared and
all of them carry oxygen, saturation is red light
100%  Anemia (Hgb <10)
o If 8 of 16 hemoglobin units carry  In physiologic anemia of pregnancy
2. Falsely Low SpO2
oxygen. saturation is 50%
 High venous pressure
Physical Properties Used in Pulse Oxymetry
 In CHF, SVC syndrome, traumatic
venous obstruction
Cellular Transport of
 Tourniquet or inflated manometer cuff Metabolism: O2 O2 and CO2
Ventilation
placed proximal to the pulse oximeter between
consumption (between cells,
alveoli and
NOTE: do not put the BP app and pulse and CO2 capilliaries,
atmosphere
production and alveoli)
ox on the same arm
 Diagnostic dyes
 Nail polish – blocks light transmission CAPNOGRAPHY
 Darker skin color  Capnography – measurement of how much CO2 is
 Have lighter nail beds present in the patient’s breath
 Pulse ox may be placed on the earlobes - Uses infrared waves that are absorbed by
3. Technical Factors (Poor or no reading) gases that have 2 or more different atoms
 Problems with sensing - CO2 maximally absorbs infrared waves at
 Due to motion (eg. when shivering) about 4.25 micrometers (4250nm)
 Low flow states - The more CO2 present, the more infrared
 Leads to insufficient change in light waves are absorbed.
emittance ∴ no reading
 Ambient light Classification:
 Increased light on photo detector
1. Main stream analyser – CO2 sensor
 Penumbra effect
located between ET ad breathing circuit
 In regions of partial illumination 2. Side stream analyser – sensor located in
NOTE: Cold temperature and active bleeding the main unit and CO2 is aspirated via a
may also alter the pulse ox reading sampling tube
Ventilation Advantages:
- Helps assess a variety of problems along

 Measured by monitoring n-tidal carbon dioxide
the pathway taken by the CO2
using capnography
- Non-invasive and rapid
o Capnography is the analysis of the
- Provide continuous measurement
continuous waveform of expired CO2 - Physically small
o Normal CO2 value: 35-45 PaCO2
Attached to the endotracheal tube before the corrugating Parts of a capnograph:
tubes
 Monitored clinically by:

1. Verifying correct positioning of the endotracheal
tube
a. Observe chest excursions – chest
expansion upon application of positive
pressure ventilation
b. Reservoir bag displacement – bag
inflates and deflates
c. Breath sounds over both lung fields
2. End tidal CO2 analysis (quantitative monitoring)
a. Measurement of expired gas volumes
b. Arterial blood gas analysis
NOTE: both are useful adjuncts in assessing the
adequacy of both oxygenation and ventilation
 Review:
EXHALATION
Exhalation
 End Tidal CO2: 45< = retaining CO2 in the

body  hypercarbia
o Need to hyperventilate by increasing
minute volume of px  tidal volume
& respiratory volume increase
 In under controlled ventilation, you need to
BLOW OFF CO2
VENTILATION (V) / PERFUSION (Q)

 Relationship between airflow in alveoli amd
blood flow in the pulmonary capillaries
 Normal = 0.8
May be:
a. Low V/Q
o Shunt perfusion
i. Alveoli perfused but not
ventilated
ii. ET tube in mainstream
bronchus
b. V/Q~0.8
o Normal
i. Alveoli perfused and
ventilated
c. High V/Q
o Deadspace ventilation
i. Alveoli ventilated but not
perfused
ii. Cardiac arrest
Note the inspiratory and expiratory limb in

mechanical deadspace
QUESTIONS:
1. What if walang upper lip in pulse oximeter,
you can use pinna of ear or lower
extremities
2. If di kaya ng breathing, you can give o2
supplementation but remember that there is
NASAL CANNULA (do not give in 10 L; max
to 6 L only of O2)
3. In all the px intubated, there should be
capnography. However, it is a separate
device from cardiac monitor and pulse
oximeter.
A. RIVA-ROCCI METHOD
- placement of an inflatable cuff around a
limb
Recommendations for the Use of Noninvasive Blood

Pressure Devices
1. Do not wrap the cuff tightly.

2. Do not apply the cuff across a joint, bony
prominence, or superficial nerve (ulnar nerve,
peroneal nerve.
Verification of proper ET tube placement 3. Select the maximum cycle time consistent with
 most important safe monitoring.
4. Inspect the cuff site periodically during
prolonged cuff application.
5. Record cuff location and cycle time.
6. Keep alarms enabled.
B. KOROTTKOFF METHOD
- A stethoscope placed over the artery distal
to the occluding cuff will detect a sound recommends using phase 5 as the diastolic
when the systolic pressure exceeds the cuff pressure except in cases in which the
pressure sound may not dependably disappear.
* Diastolic blood pressure is the pressure observed at
phase 4 or 5.
BP CUFF SIZE
 influences the measurement of blood pressure.
 Too small: will result in a reading that is
inappropriately high;
 Larger cuff: indicated may show a lower than
accurate decreased blood pressure reading.
 The cuff is appropriately sized when its width is
40% the circumference of the arm.
 Variations in arterial blood pressure may also
result with changes in posture.
 The diastolic blood pressure is routinely
somewhat higher in the sitting patient.
SYSTOLIC BLOOD PRESSURE

4 Phases:
a. Phase 1
- Systolic blood pressure is consistent with
the first sound heard during deflation of the
blood pressure cuff
b. Phase 2 & 3
- As the cuff is deflated the sound changes in
quality Always at the level of 4th intercostal space
c. Phase 4
- occurs with sudden onset of a muffled If in lateral, it should be based on the dependent
sound side of the px.
d. Phase 5
- absence of any sound
- The American Heart Association
C. OSCILLOMETRIC METHOD  Used for coronary artery bypass

 Continuous blood pressure monitoring is
accomplished by placement of a catheter in a
peripheral (usually radial) artery, which is
connected to a transducer system and display.
Direct blood pressure monitoring is indicated
 during cardiopulmonary bypass,
 when wide swings in blood pressure are
expected,
 when rigorous control of blood pressure
is necessary, and
 when there is a need for multiple
analyses of arterial blood gas
D. DINAMAP METHOD measurements.
 (device for indirect noninvasive automatic mean
arterial pressure) CANNULATION SITE
 is an automated blood pressure measurement  The most frequently chosen site for arterial
device cannulation is the radial artery
 uses the oscillometric technique  close to the skin surface and is relatively
- The oscillometric variation is compared at easily palpable compared to some
each reduction in cuff pressure. deeper arterial sites.
- Automated blood pressure measurements  Other acceptable sites for arterial pressure
generally correlate well with the systolic monitoring:
- and mean blood pressures as measured  brachial,
with intra-arterial catheters.  axillary,
- However, the diastolic pressure is usually  dorsalis pedis, and
about 10 mm Hg higher with automated  femoral arteries
devices than with direct arterial
measurements
All mentioned before are non-invasive
E. DIRECT ARTERIAL PRESSURE MONITORING
COMPLICATIONS OF ARTERIAL LINES

 includes:
 distal ischemia, infection, and
hemorrhage.
 The rate of distal ischemia after radial artery
 Invasive catheterization is less than 0.1%.
ELECTROCARDIOGRAM (ECG)
- displays cardiac rhythm and rate and can

also detect cardiac ischemia.
F. CENTRAL VENOUS PRESSURE MONITORING

 Pressure in the right atrium
 used to monitor right ventricular filling when it is
the clinically critical structure or to measure left
ventricular filling when there is a correlation ECG LIMBS
between left and right ventricles.  The standard bipolar limb leads I, II, and III, and
 A normal CVP reading range: 2-7 mm Hg. the augmented unipolar leads aVR, aVL, and
aVF provide the clinician with important, though
 The filling pressure is used as an indicator of
limited, views of the myocardium.
cardiac volume with the understanding that
adequate volumes will generate optimal cardiac  Because the electrical vector of lead II parallels
contractility. the atrial and ventricular depolarization waves,
one can normally obtain large P waves and QRS
 When the ventricle is underfilled, large volume
complexes when using this limb lead.
changes will generate little increase in the CVP,
but small volume changes will generate large  However, monitoring of cardiac ischemia is
increases in CVP in an overfilled ventricle. significantly enhanced by use of the precordial
leads V1 through V6.
 A normal ECG is composed of a P wave, PR
interval, QRS complex, ST segment, and T
wave, perhaps followed by a U wave.
o P wave: wave of depolarization
generated by the sinoatrial node, which
is normally situated in the right atrium.
The impulse travels through the
atrioventricular node through the bundle
of His down the Purkinje fibers to the
ventricle.
o QRS complex: ensues when the
ventricle contracts in response to the
electrical stimulation.
o T wave: follows the QRS complex with
the commencement of repolarization
TRANSER’S SPACE
REFERENCES
● Pardo, M., & Miller, R. D. (2017). Basics of
Anesthesia E-Book. Elsevier Health Sciences.
END OF TRANSCRIPTION
REVIEW QUESTIONS
1. Stage of anesthesia when patients are in deep sleep
and muscles are flaccid.
2. Drug that may affect the pupillary size and make eye
size unusable.
3. T or F. Anesthetic agents are cardiopulmonary
antidepressants.
4. T or F. Oxygenation may also be obtained from the
earlobes.
5. The first Korotkoff sound is the snapping sound is
considered as the _____ Courtesy:
6. Phase of systolic blood pressure where there is
https://www.facebook.com/MedicalMemesForSleepDeprived
absence of any sound
7. Indicator of cardiac volume with the understanding
Kids
that adequate volumes will generate optimal cardiac
contractility
8. Most frequently chosen sire for arterial cannulation
Answers: 1. Stage III: Surgical anesthesia, 2. Atropine, 3. False. Stage 2/Delirium stage starts with loss of
consciousness and excitement is noted, 4. True, 5. Systolic pressure 6. Phase 5 7. Filling pressure 8. Radial
artery

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DR. RITCHE AGCAOILI SEPT.

 Stage I- Analgesia (loss of pain sensation)

Stage 1: Amnesia and Analgesia

o Cardiac arrest 1. Amount of light absorbed is proportional to the

- Helps assess a variety of problems along

 Monitored clinically by:

 End Tidal CO2: 45< = retaining CO2 in the

VENTILATION (V) / PERFUSION (Q)

Note the inspiratory and expiratory limb in

Recommendations for the Use of Noninvasive Blood

1. Do not wrap the cuff tightly.

SYSTOLIC BLOOD PRESSURE

C. OSCILLOMETRIC METHOD  Used for coronary artery bypass

All mentioned before are non-invasive

E. DIRECT ARTERIAL PRESSURE MONITORING

COMPLICATIONS OF ARTERIAL LINES

- displays cardiac rhythm and rate and can

F. CENTRAL VENOUS PRESSURE MONITORING

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