Module name 1

Aim of monitoring
• Monitoring is important to prevent anesthesia complication.
Types of monitoring (Standard ASA monitors)
❑ Standard I: Qualified doctors present in the room.
❑ Standard II: instrumental monitoring, which can be classified using 2 methods
1) Basic & Advanced
a. Basic: should be continuously evaluated for all patients during anesthesia
1. Pulse oximeter (oxygenation monotring)
2. Capnography (Ventilation monotring; used during general anesthesia only)
3. Noninvasive blood pressure & ECG (circulation monitoring at least every 5 min)
4. Temperature monitoring
b. Advanced: According to patient & surgery
2) Systemic classifications:
a. CVS c. Respiratory e. MSK
b. Blood loss d. Expired Gas f. CNS

1.
A. Non - invasive B. Semi - invasive C. Invasive
1) ECG Transesophageal 1) invasive blood pressure
2) Noninvasive blood Echocardiography (TEE) 2) central venous pressure
pressure 3) pulmonary artery catheterization
A. Non - invasive
Contiguous leads in ECG: To detect the site of MI
1) ECG: mandatory monitor to
detect:
a. Arrhythmia lead II
b. Ischemia lead V5
c. cardiac arrest: flat line

2) Noninvasive blood pressure (NIBP)

o Measure blood pressure at set intervals automatically by automated oscillometery.
o Cuff size should cover 2/3 of arm (→ Smaller cuff for children & larger cuff for obese)
• Too large (underestimate)
• Too small (overestimate)
 2 Monitoring in anesthesia

B. Semi – invasive: Transesophageal Echocardiography (TEE):

Most sensitive to detect any wall motion abnormality.
a. ischemia,
b. valvular dysfunction,
c. air embolism

C. Invasive Monitoring
1) invasive blood pressure (IBP)
o Accuracy: More Accurate than NIBP
o Indications Required in patient mandates for beat-to-beat monitoring,
e.g. Major surgeries as open heart surgeries
o Site of measurement
a) Radial Artery (most common site; after Allen's Test, see below)
b) Brachial Artery
c) Femoral Artery
d) Dorsalis Pedis Artery
o Complications:
a) Arterial injury, which may lead to
- Hemorrhage - Fistula and aneurysm formation
- Spasm & distal ischemia - Thrombosis, embolization
b) Infection & Sepsis
c) Tissue necrosis

Allen's Test
• Aim: Allen's test is performed before radial artery cannulation to determine whether ulnar
collateral circulation to the hand is adequate in case of radial artery thrombosis.
• Technique:
1. The hand is exsanguinated by having the patient make a tight fist.
2. The radial and ulnar arteries are occluded by manual compression, the patient relaxes the
hand, and the pressure over the ulnar artery is released.
3. Collateral flow is assessed by measuring the time required for return of normal coloration:
a. Return of color in less than 7 seconds indicates adequate collateral flow,
b. Return in 7 to 10 seconds suggests an equivocal test,
c. Return in more than 10 seconds indicates inadequate collateral circulation
→ contraindicated
 Module name 3

2) central venous pressure (CVP)

o Sites of insertion:
1. Internal Jugular,
2. Subclavian
3. Femoral veins
o Indications
1. Monitoring
a. Major surgeries where large fluctuations in hemodynamics are expected.
b. Open heart surgeries.
2. As a venous access.
a. Fluid management in shock.
b. Parenteral nutrition.
c. Aspiration of air embolus.
3. Cardiac pacing.
o Normal value:
• Adult: 3 - 10 cm of H2O (or 2- 8 mmHg).
• Children 3 - 6 cm
CVP more than 20 cm of H2O indicates right heart failure.
3) pulmonary artery catheterization:
o By Swan Ganz catheter
o measure pulmonary arterial wedge pressure to which reflect the left atrial pressure.
 4 Monitoring in anesthesia

2.
• Estimation of blood loss is done by weighing blood-soaked swabs, sponges (Gravimetric method)
and estimation of blood loss in suction bottle (Volumetric method).
• Most accurate method is colorimetric method.
• On an average (a rough guide):
‫صغيين (عشان أنقل دم لو وصل الفقد لل ـ ـ ـ ـ ـ ـ ـ‬
‫ر‬ ‫ لو شوية‬50 ‫ لو يف النص‬100 ، ‫ لو متعرصة دم‬150 ← 45 × 45 ‫فوطة‬
Transfusion point 20 % in Adult, 10 % in pediatric

3.
A. Pulse oximetry E. Lung volumes
B. Capnography F. Oxygen analysers
C. Blood gas analysis G. Airway pressure monitoring
D. Lung volumes H. Apnea monitoring

A. Pulse oximetry
𝑜𝑥𝑦𝑔𝑒𝑛 𝑐𝑜𝑛𝑡𝑒𝑛𝑡
▪ Measures Oxygen saturation (SpO2) (𝑜𝑥𝑦𝑔𝑒𝑛 saturation = )
𝑜𝑥𝑦𝑔𝑒𝑛 𝑐𝑎𝑝𝑎𝑐𝑖𝑡𝑦

▪ Uses: detection of hypoxia intra/post operative

▪ Normal value: 97 - 98 %
▪ Probe is applied at
a. finger c. toe nail bed , e. tip of nose
b. nail bed, d. ear lobule,
▪ Factors affecting reading
1) Presence of abnormal Hb
a. false high as in carboxy Hb SO2 95%
b. false low as in met Hb SO2 85%
2) Hypoperfusion (hypotension, hypothermia and VC).
3) Others: MADS
a. Motion & shivering c. Diathermy & ambient light.
b. Anemia d. Skin pigmentation & dye
 Module name 5

B. Capnography (ET CO2):

Important and sensitive monitoring
▪ It is the continuous measurement
of end tidal (expired) CO2 (ETCO2)
& its waveform.
▪ Normal: 32 - 42 mmHg
(3 - 4 mmHg less than arterial
pCO2 which is 35 to 45 mmHg but
for some authors normal ET CO2 is
35 – 45 mmHg).
C. Blood gases:
▪ Important in
o Thoracic surgery
o Hypothermia
o Hypotensive anesthesia
▪ Normal value
Value Arterial blood gases Mixed venous gases
pH 7.35-7.45 7.30 -7.40
PaCO2 35-45 mmHg 40-50 mmHg
PaO2 80-100 mmHg 35-40 mmHg
SaO2 > 95% 70-75%
HCO3 22-26 mEqL 22-26 mEqL (up to 28)
Base deficit -3 to +3 ‫المطلوب من هذا العمود تحته خط‬
D. Mixed venous blood oxygenation (SvO2)
▪ Sampling
o Mixed venous blood oxygenation (SvO2): blood sample is taken from the proximal
pulmonary artery.
o Central venous oxygen saturation (ScvO2), measured by the placement of a catheter in
the superior vena cava, can be taken as a surrogate for SvO2.
▪ Normal value: see table above.

Note
• Mixed venous oxygen in the best indicator of cardiac output i.e., tissue oxygenation
• Arterial oxygen is the better indicator of pulmonary function.

4.
There is a multi-gas analyzer which measures concentration of anesthetic vapors like nitrous oxide
and inhalational agents like halothane, isoflurane etc.
 6 Monitoring in anesthesia

5.
Aim
Temperature Monitoring is very important because of High incidence of intra-operative
hypothermia.

Monitoring sites of Core temperature

1. Esophagus
2. Pulmonary artery
3. Nasopharynx
4. Tympanic membrane — most accurate for brain temperature

Hypothermia
❑ Definition: core temperature less than 35 C.
❑ Degrees:
• Mild: 28-35 oC
• Moderate: 21-27 oC
• Severe: 20 oC
❑ Importance: Most common thermal perturbation seen in anesthesia because:
1. Most anesthetics are vasodilators, causing heat loss and
2. hypothermia 4. Cold intravenous fluids.
3. Cool room temperature 5. Evaporation

❑ Hazards
1. CVS:
• Bradycardia
• Hypotension
• Ventricular arrhythmias if temperature is less than 28 oC
2. Respiratory system:
• Respiratory arrest below 23 oC
• O2 dissociation curve is shifted to left
3. Blood: Increased blood viscosity and platelet count.
4. Acid base balance
• Increased solubility of blood gases
• Acidosis — increased lactic acid production d/t blood stasis
5. Kidney
• Decreased GFR
• No urine output at 20 oC

6. Endocrine system
• Decreased adrenaline & nor-adrenaline
• Hyperglycemia
 Module name 7

❑ Treatment
1. Warm intravenous fluids
2. Increase room temperature: The ideal operation theatre temperature for adults is 21 oC
and for the children 28 oC.
3. Cover the patient with blankets.
4. Forced warm air by a special instrument ( Bair Hugger airflow device).

6.
Monitoring Depth of Anesthesia
A. Clinically: Signs and symptoms of light anesthesia are:
1) CVS
• Tachycardia.
• Hypertension.
2) Respiratory
• Tachypnea, breath holding, • bronchospasm
• Coughing, • laryngospasm,
3) Neuromuscular
• Movement response to painful stimuli.
• Lacrimation. • Perspiration.
• Eye movements. • Preserved reflexes

B. Instrumental:
1) EEG & Entropy
( Entropy detection of abnormalities in EEG at higher concentration of anesthetic agents)
2) Patient evoked response
3) Bi-spectral index:
processes electroencephalographic signals to obtain a Numerical value, which reflects the
level of consciousness of the patient:
Value Meaning
100 Fully awake
40 – 60 adequate general anesthesia
< 40 deep hypnotic state
0 EEG silence

َ َّ
ُ ‫األي‬
‫ـام ُمرسعـة‬ ‫ـمر و‬ ُ
ِ ‫ـلة الع‬
ِ ‫ي ِرح‬
َ َّ ُ َ
‫السف ِر‬ ‫ أو َما وجهة‬،‫تنس َمن أنت‬
َ ‫ال‬