PHYSIOLOGIC MONITORING

• radial artery at the wrist is the site most

Catherine Joyce D. Magno, MD, FPSGS, FPCS
commonly used

• Central (i.e., aortic) and peripheral (e.g.,

• Monere - monitor, warn, advise
radial artery) pressures typically are dif-
• Take appropriate actions
ferent as a result of the impedance and
• ICU OR
inductance of the arte- rial tree. Systolic
Integration of physiologic data obtained from pressures typically are higher and diastolic
monitoring into a coherent evidence-based pressures are lower in the periphery,
treatment plan
whereas mean pressure is approximately the
same in the aorta and more distal sites.

ARTERIAL BLOOD PRESSURE • Complications

- systemic arterial system

• Distal ischemia is an uncommon

• incidence of thrombosis is increased

Non invasive monitoring
when larger-caliber catheters are
• use an inflatable sphygmomanometer cuff employed

to increase pressure around an extremity • retrograde embolization of air bubbles

and to detect the presence or absence of or thrombi into the intracranial
arterial pulsations.
circulation.

• Korotkoff sounds, which are heard over an • relatively uncommon complication of

artery distal to the cuff as the cuff is intra-arterial lines used for monitor-
deflated
ing, occurring in 0.4% to 0.7% of
• Systolic pressure is defined as the pressure catheterizations

in the cuff when tapping sounds are first

audible. Diastolic pressure is the pressure in ELECTROCARDIOGRAPHIC MONITORING
the cuff when audible pulsations first • records the electrical activity associated
disappear.
with cardiac contraction by detecting
• Another means for pulse detection when voltages on the body surface.

measuring blood pressure noninvasively • standard 3-lead ECG is obtained by placing

depends upon the detection of oscillations electrodes that correspond to the left arm
in the pressure within the bladder of the (LA), right arm (RA), and left leg (LL).

cuff: unreliable
• The limb leads are defined as

• Doppler stethoscope
• lead I (LA-RA),

• pulse oximeter
• lead II (LL-RA), and

• photoplethysmography
• lead III (LL-LA)

• providing continuous information,

• 12 lead ECG - precordial lead V4 is the
• uses the transmission of infrared light to most sensitive for detecting perioperative
estimate the amount of hemoglobin in a ischemia and infarction.

finger placed under a servo- controlled

inflatable cuff.
Cardiac output and related Parameters

• less accurate in patients with Determinants of Cardiac performance

hypotension or hypothermia.
• Preload

• Determined by end-diastolic volume

Invasive monitoring
• R vent: CVP, approximated RV EDP

• using fluid-filled tubing to connect an intra- • L vent: pulmonary artery occlusion

arterial catheter to an external strain-gauge pressure (PAOP) approximately LV
transducer
EDP

• signal generated by the transducer is • Afterload

electronically amplified and displayed as a • Force resisting fiber shortening once

continuous waveform by an oscilloscope or systole begins

computerized display.
• Approximated by calculating systemic
• clinical decisions based primarily on the vascular resistance = mean arterial
measured mean arterial blood pressure.
pressure (MAP)/cardiac output

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 • Contractility
RESPIRATORY MONITORING
• Inotropic state of the myocardium\
• Assess the adequacy of oxygenation and
• Difficult to quantify
ventilation

• Guide weaning and liberation from

PULMONARY ARTERY CATHETER mechanical ventilation

• requires access to the central venous • Detect adverse events associated with
circulation. Such access can be obtained at respiratory failure and mechanical
a variety of sites, including the antecubital, ventilation

femoral, jugular, and subclavian veins.

• Parameters: gas exchange, neuromuscular
• Right internal jugular vein cannulation activity, respiratory mechanics, and patient
carries the lowest risk of complications, and effort.

the path of the catheter from this site into

the right atrium is straight.
ARTERIAL BLOOD GAS
• Used to optimize cardiac output and • detect alterations in acid-base balance due
systemic oxygen delivery, however it is not to low QT, sepsis, renal failure, severe
recommended for routine use
trauma, medication or drug overdose, or
altered mental status.

MINIMALLY INVASIVE ALTERNATIVES • can be analyzed for pH, Po , Pco , HCO –

TO PAC concentration and calculated base deficit.
• Transpulomnary thermodilution
• involve removal of an aliquot of blood from
-measures temperature changes from the patient, although continuous bedside
cold bolus solution injected centrally, arterial blood gas determinations are now
then measured using an arterial possible without sampling via an indwelling
thermistor on a special arterial line, arterial catheter that contains a biosensor.

generally placed in the femoral artery.

• Continuous monitoring can reduce the
• Doppler Ultrasonograhy
volume of blood loss due to phlebotomy but
- calculate red blood cell velocity
is expensive and is not widely employed.

• Imedance cardiography

-provides a continuous readout of QT

DETERMINANTS OF OXYGEN DELIVERY
• Pulse contour analysis
• Systemic O2 delivery (DO2) is dependent on
-estimating QT uses the arterial the oxygen saturation of hgb in arterial
pressure waveform as an input for a blood

model of the systemic circulation in • Dependent of cardiac output (QT) and

order to determine beat-to-beat flow hemoglobin

through the circulatory system

• Partial CO2 rebreathing

PEAK AND PLATEAU AIRWAY PRESSURE
-Fick principle to estimate QT
• Airway pressure are routinely monitored in
• Transesophageal echocardiography (TEE)
mechanically ventilated patients

-global assessments of LV and RV • Peak airway pressure (Ppeak)

function can be made, including • measured at the end of inspiration

determinations of ventricular volume, • a function of the tidal volume, the

EF, and QT.
resistance of the airways, lung/chest
• Assessing preload responsiveness
wall compliance, and peak inspiratory
• Near infrared spectroscopic measurement flow.

of tissue hemoglobin O2 sat.

• Plateau airway pressure (Pplateau)

-continuous, nonin- vasive • measured at the end of inspiration when

measurement of tissue hemoglobin the inhaled volume is held in the lungs
oxygen saturation (StO2) using near- by briefly closing the expiratory valve

infrared wave lengths of light (700–

1000 nm).

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VENTILATOR INDUCED LUNG INJURY (VILI) • diagnosis of ACS is the presence of an IAP
• Excessive airway pressure and tidal volume ≥20 mmHg recorded by three
adversely affect pulmonary and possibly measurements 1 to 6 hours apart,

systemic responses to critical illness

• barotrauma can result in parenchymal lung NEUROLOGIC MONITORING

injury, diffuse alveolar damage similar to Intracranial pressure

ARDS, and pneumothorax.

• Monitoring of ICP is currently recommended
in patients with severe traumatic brain injury
PULSE OXIMETRY
(TBI), defined as a Glasgow Coma Scale
• microprocessor-based device that (GCS) score less than or equal to 8 with an
integrates oximetry and plethysmography to abnormal computed tomography (CT) scan,
provide continuous noninvasive monitoring and in patients with severe TBI and a
of the oxygen saturation of arterial blood normal CT scan if two or more of the
(Sao2)
following are present: age >40 years,
• accuracy of pulse oximetry begins to unilateral or bilateral motor posturing, or
decline at Sao2 values less than 92% and systolic blood pressure <90 mmHg
tends to be unreliable for values less than • The goal is to ensure adequate cerebral
85%
perfusion pressure to support perfusion of
• reduction in unrecognized deterioration, the brain

rescue events, and transfers to the ICU.

• CPP = MAP - ICP

CAPTOMETRY Intracranial pressure monitoring

• measurement of carbon dioxide in the • The ventriculostomy catheter, consists of a

airway throughout the respiratory cycle
fluid-filled catheter inserted into a cere- bral
• most commonly measured by infrared light ventricle and connected to an external
absorption.
pressure transducer. This device permits
• allows the confirmation of endotracheal measurement of ICP but also allows drain-
intubation and continuous assessment of age of cerebrospinal fluid (CSF) as a means
ventilation, integrity of the airway, operation to lower ICP and sample CSF for laboratory
of the ventilator, and cardiopulmonary studies.

function.
• associated complications

• Infection (5%)

RENAL MONITORING • Hemorrhage (1.1%)

Urine Output
• Catheter malfunction or
• monitored through bladder catheterization
obstruction (6.3-10.5%)

• Gross indicator of renal perfusion

• maintaining ICP less than 25 mmHg in
• normal urine output is 0.5 mL/kg per hour patients without craniectomy and less than
for adults and 1 to 2 mL/kg per hour for 15 mmHg in patients with craniectomy is
neonates and infants.
associated with improved outcome

• Oliguria may reflect inadequate renal artery

perfusion due to hypotension, hypovolemia, Electroencephalogram and evoked potentials

or low QT.
• EEG - monitor global neurologic electric
Bladder pressure
activity

• instilling 50 to 100 mL of sterile saline into • Evoked potentials - assess the pathways
the bladder via a Foley catheter, the tubing not detected by the conventional EEG

is connected to a transducing system to • Useful in obtruded and comatose patients

measure bladder pressure in the supine • Somatosensory and brain stem evoked
position at end-expiration.
potentials are less affected by
• Intra-abdominal hypertension is defined as administration of sedatives than with EEG

an IAP ≥12 mmHg recorded on three

standard measurements conducted 4 to 6
hours apart and is separated into several
grades.

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Transcranial Doppler Ultrasonography

• noninvasive method for evaluating cerebral

hemodynamics

• measurements of middle and anterior

cerebral artery blood flow velocity

• useful for the diagnosis of cerebral

vasospasm after sub- arachnoid
hemorrhage.

Jugular Venous Oximetry

• changes in jugular venous oxygen

saturation (Sjo2) reflect changes in the
difference between cerebral oxygen delivery
and demand.

• decrease in Sjo2 reflects cerebral

hypoperfusion, whereas an increase in Sjo2
indicates the presence of hyperemia.

• Low Sjo2 is associated with poor outcomes

after TBI

Transcranial Near-Infrared Spectroscopy

• noninvasive continuous monitoring method

to determine cerebral oxygenation.

Brain Tissue Oxygen Tension

• monitoring local brain tissue oxygen tension

(PbtO2) may be a useful adjunct to ICP
monitoring in patients with sever TBI

• Normal values for PbtO2 are 20 to 40

mmHg
• critical levels are 8 to 10 mmHg.
• early detection of brain tissue ischemia
despite normal ICP and CCP

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