• Internal Jugular Vein :

1. Central Approach:
find 1cm above the apex of head of SCM and clavicle > 60’to skin, towards ipsilateral nipple (blood obtained within 3cm)
2. Posterior Approach:
find 2-3 finger above clavicle along posterior border of SCM, direct needle towards jugular notch (blood obtained within 5cm)
3. Anterior approach:
identify the carotid and mid point of medial SCM border, aim toward ipsilateral nipple

• Subclavian Vein :
1. Subclavian Approach:
find 1 cm inferior to the junction of middle and medial third of the clavicle, and advance the needle toward suprasternal notch
2. Supraclavicular Approach:
find 1 cm lateral to the lateral border of clavicular head of SCM, and 1 cm superior to clavicle, and advance the needle toward
contralateral nipple

• Femoral Vein :
1. Approach:
slight external rotation of hip, palpate pulse, 1 cm medial to arterial pulsation, and advance the needle with 45’ in a cephallad
 ARTERIAL LINE
• Component :
1. An indwelling Teflon cannula 22G is used
2. A column of bubble-free heparinized saline at a pressure of 300 mmHg
3. Transducer, Amplifier, Oscilloscope, and Diaphragm

• It can estimate Blood Pressure, Myocardial Contractility, P.V.Resistance, & stroke

Volume

• The natural frequency of the monitoring system is :

1. Directly related to the catheter diameter
2. Inversely related to the Square root of the System Compliance
3. Inversely related to the Square root of the Length of the Tubing
4. Inversely related to the Square root of the Density of the Fluid
• DAMPING is caused of dissipation of stored energy
• Optimal Damping = 0.64

• The addition of tubing, stopcocks, soft transducer, and air in the line, all
Decrease the Frequency of the system, leading to Over-Damping, and so
Underestimate the Systolic BP but Normal Mean BP

• The transducer should be positioned at the level of Right Atrium

( raising or lowering that level will give error readings by 7.5 mmHg for 10 cm )

• The Site of choice for insertion is Radial Artery ( after performing Allen’s Test)
, because it is more superficial than Ulnar artery and having good collaterals
 PULSE OXIMETRY
• It consists of a Probe with two LEDs and a Photodetector

• The two Light Emitting Diodes LEDs produce beams at red (660 nm) and
infrared (940 nm) frequencies, in a rate of 30 times per second

• Oxygen Saturation is estimated by measuring the transmission of light

through a pulsatile vascular bed, based on Lambert-Beer Law

• It gives readings every 10-20 seconds

• The response time of desaturation is longer with finger probe (60 seconds)
whereas in ear probe it is shorter (15 seconds)
• Oxy-hemoglobin absorb infrared light (940 nm) and Deoxy-hemoglobin
absorb red light (660 nm), while both are equal in absorption at (805 nm)

• Arterial Pulsations can be identified by Plethysmography

• Sources of Error Readings :

1. Met-Hb 2. CO poisoning 3. Methylene Blue 4. Blue Nail
varnish
5. Hypothermia 6. Low Perfusion 7. Sensor Malposition 8. Severe
Anemia

• Fetal Hb, Bilirubin, & Dark Skin, all do not cause significant errors
 CAPNOGRAPHY
• End-Tidal CO2 is less than Alveolar CO2 because it is diluted with alveolar dead
space gas, while the Alveolar CO2 is less than Arterial CO2 due to shunt

• CO2 absorbs the infrared radiation at (430 nm), based upon Beer-Lambert Law

• in the above diagram, the End-Tidal CO2 is read at the point marked as (D)

• Sampling can be done either by Sidestream Chamber or Mainstream Chamber

• Mainstream : 1. faster 2. risk of sensor damage 3. heavy weight on the tube
• Sidestream : 1. slower 2. risk of disconnection 3. risk of gas leak

• Special Filter should be used, because N2O can also absorb the infrared light
• Increased ETCO2 : 1. Hypoventilation 2. Malignant Hyperthermia 3.
Sepsis
• Decreased ETCO2: 1. Hyperventilation 2. Pulmonary Embolism 3. Low
BP
• No ETCO2 : 1. Esophageal Intubation 2. Circuit Disconnection
 BISPECTRAL INDEX
• It monitors : 1. Electrical Activity in brain 2. Level of Sedation
3. Awareness under anesthesia 4. Titration of Hypnosis

• It contains a Forehead Sensor with Four numbered Electrodes and a Smart

Chip
* Number 1 … at the center of forehead, 5 cm above the nose
* Number 4 … just above and adjacent to the eyebrow
* Number 2 … between number 1 and number 4
* Number 3 … on either temple between corner of eye and the hairline

• BIS can not be used to monitor hypnosis during Ketamine anesthesia

• Sedative effect of 70% Nitrous Oxide do not affect BIS
 ELECTROENCEPHALOGRAPHY
• EEG is composed of 16-25 electrodes attached to the scalp

• The brain cells communicate via electrical impulses and are active all the time
even when the patient is asleep

• EEG activity occurs mostly at frequencies between 0.5-30 Hz

• Waves normally range from 1-500 micro-volt in Amplitude

• EEG Waves : Beta ..… 13 - 30 Hz ….. ( in concentrating individuals )

Alpha ….. 8 - 13 Hz ……. ( in resting adults with closed eyes )
Theta .….. 4 - 8 Hz …….. ( in sleeping individuals )
Delta ..….. 0.5 - 4 Hz ….. ( in brain injury and anesthesia )
 PERIPHERAL NERVE STIMULATOR
• It delivers a current of ( 15-50 mA ) to a pair of ECG silver-chloride pads or
subcutaneous needles placed over a peripheral motor nerve

• The negative electrode is positioned over the most superficial part of the
nerve, while the positive electrode along the proximal course of the nerve

• The most commonly monitored sites are :

1. Ulnar Nerve stimulation of Adductor Pollicis Muscle
2. Facial Nerve stimulation of Orbicularis Muscle

• The duration of stimulus is less than 0.2 ms ( < 200 micro-seconds )

• All stimuli are having Equal current, with a Square-Wave Pattern
• Single Twitch :
* Frequency ( 0.1 - 1 Hz ) * Increasing block results in decreased evoked response

• Tetanic Stimulation :
* Frequency ( 50 - 100 Hz ) * sustained contraction for 5 seconds is adequate for reversal

• Train-of –Four :
* Four twitches of ( 2 Hz ) each applied over ( 0.2 ms ) with a gap of ( 500 ms )
* On Fading : Disappearance of 4th then 3rd then 2nd then 1st
* 4th … 75% block , 3rd … 80% block , 2nd … 90% block
* Clinical relaxation usually requires 75-90 % neuromuscular blockade
* On recovery : Appearance of 1st then 2nd then 3rd then 4th
* Reversal is easier if 2nd twitch is visible

• Double Burst Stimulation :

* Two variations of tetany * less painful * most accurate
* Two Short bursts of ( 50 Hz ) with interval of ( 750 ms )
* Each burst compromise of two to three impulses lasting for ( 0.2 ms )