Anesthesia

Monitoring
Dr. Lamia Saryah
 Introduction
Monitoring during anaesthesia is very important
to prevent complications

Sophisticated monitors are available

Not to fully depend on.

 basic
Monitoring
advanced
Advanced ( instrumental)
• CVS
• Respiratory system
• Temp
• Neuromuscular
• CNS
• Blood loss
The cardiovascular system

•clinically:
• Capillary refill time
• urine output and
• pulse volume
Non invasive:
• ECG: Mandatory to detect:
1. Arrhythmia
2. Ischemia
3. Cardiac arrest

• The commonest position of the

electrodes is the CM5
arrangement as this is the best
position to detect ischaemia of
the left ventricle
Non invasive:
• Indirect methods: Oscillometric:
• Measures BP at set intervals
automatically
by automated oscillometery.

• Cuff size should cover 2/3 of the arm

• To larger cuff > underestimate
• To small cuff > overestimate
Invasive
• Direct measurement: Gold standard
• Required in patient mandates for
beat to beat monitoring
• Site:
• Radial a.
• Brachial a.
• Femoral a.
• Dorsalis pedis a.
Allen’s test
• Normal < 7s
• Borderline 7 – 14 s
• Contraindicated > 15s

• Cannula complications:
• Arterial injury, spam, distal ischemia
• Thrombosis, embolization
• Sepsis
• Fistula formation
Central venous pressure
• Indication:
• Major surgeries
• As an iv access
• Parenteral nutrition
• Aspiration of air embolism
• Cardiac pacing

Normal cvp is 3 to 10 cmH2o ( 2-8 mmHg)

CVP > 20 cmH2O indicates right side HF
Central venous pressure
• Site of cannulation:
• Internal jagular
• Subclavian
• Femoral

• Chest x ray is performed to check the position

of catheter
Central venous pressure
• Complications:
• Air embolism
• Arrhythmias
• pneumothorax/hemothorax/chylothorax
• Cardiac tamponade
• Sepsis
• Trauma to brachial plexus, carotid artery
Pulmonary artery pressure
• The pulmonary artery flotation catheter (PAFC, or
Swan-Ganz catheter) enables measurement of left-
sided pressures
• It is rarely used now
• Reserved only for major cases
• Swan Ganz catheter – is a balloon, tipped and flow
directed by pressure recording, pressure tracing, and
catheter tip.
Pulmonary artery pressure
CVP
• Measures in vena cava
• It’s value is related to the
volume of blood in the veins and
is approximately equal to RAP
PCWP
• Measured by advancing a
catheter through the pulmonary
artery until it “wedges” in the
artery’s smallest branch.
• at that point, the catheter
senses pulmonary capillary
pressure, which is nearly equal
to the left atrial pressure
Cardiac output
• The Fick principle
• Indicator dilution
• Chemical indicator dilution
• Thermal indicator dilution
• Pulse contour analysis
• Doppler ultrasonography
The respiratory system
• Clinical:
• Airway obstruction: tugging, paradoxical chest
movement and poor movement of the reservoir bag
• Auscultation can confirm normal breath sounds and
detect abnormalities such as bronchospasm or
excess secretions
• Respiratory rate Respiratory rate may be timed
clinically or derived from a capnograph.
The respiratory system
• Pulse oximetry
• Capnography
• Blood Gas analysis
• Lung Volumes
• Oxygen analysers
• Airway pressure monitoring
• Apnea monitoring
Pulse oximetry
• Oxygen Saturation – SpO2 ( normal > 96%)
• it detect hypoxia

• Probe is applied at:

• Finger
• Nail bed
• Ear lobule
• Tip of nose
Pulse oximetry
• Errors:
• Carboxyhemoglobin
• Methhemoglobin
• Anemia
• Hypovolumia and vasoconstriction
• Nail polish
• Shivering
• SpO2 < 70%
• Skin pigmentation
• Dyes
Capnography
• It is a continuous measurement of end tidal C02
ETCO2 and it’s waveforms
• Normal range 32 to 42 mmHg
• Principle : infrared light absorbed by C02
• Important and sensitive monitor
Others
• Lung volumes – spirometer
• Airway pressure monitoring:
• It should be less than 20 -25 cmH2O
• Low pressure – disconnection
• High pressure – obstruction in tube or circuit and bronchospasm
• Oxygen analyzer
• Monitors actual value oxygen delivered
• Fitted in inspiratory limb of breathing circuit
• Useful in closed circuit
Apnea monitoring
• it is cessation of respiration for more than 10
sec.

• By capnography – most sensitive and cost

effective
• Airway pressure
Temperature monitoring
• High incidence of intra – op hypothermia:
• Cardiac surgery
• Infants
• Children
• Adults with burns
• Febrile pt
• MH patients
Temperature monitoring

• Site for core temp monitoring:

• esophagus
• Pulmonary artery
• Nasopharynx
• Tympanic membrane
hypothermia
• It is defined as core body temperature less than 35 C
• Mild : 28-35 C
• Moderate : 21-27 C
• Sever : < 20 C

• Causes if hypothermia under anesthesia:

• Most anesthetics are vasodilators causing heat loss
• Cool room temp
• Cold iv infusions
• evaporation
hypothermia
• Systemic effects of hypothermia:
• Respiratory system
• Respiratory arrest below 23C
• O2 dissociation curve is shifted to left
• Blood
• Increase blood viscosity and decrease plt count
• CVS:
• Bradycardia
• Hypotension
• Ventricular arrhythmias
hypothermia
• Cont systemic effect of hypothermia:
• Acid base balance
• Increase solubility of blood gases
• Acidosis
• Kidney
• Decrease GFR
• No urine output at 20 C
• Endocrine system
• Hyperglycemia
Treatment if intra-operative
hypothermia
• Warm iv fluids
• Increase room temp
• Cover the patient with warm blankets
• Forced warm air ( bair hugger airflow device)
Induced hypothermia
• Brain protection in cardiac arrest or neurovascular
surgeries and for tissue protection against ischemia in
cardiac surgeries
Neuromuscular monitoring
• Train of four is the most useful method for clinical
monitoring.
• Consist of 4 stimuli, each is 2 Hz for 2 sec are given and recorded.
• Normal amplitude hight of fourth and first response will be the
same; T4/T1 = 1

• Required for:
• Myasthenia gravis
• Duchenne’s muscular dystrophy
Neuromuscular monitoring

• Site for monitoring:

• Adductor pollicis (ulnar nerve)
• Orbicularis oculi
• Median nerve
• Post. Tibial nerve
• Peroneal nerve
Neuromuscular monitoring

• Other stimuli used for neuromuscular

monitoring:
• Single twitch
• Tetanic stimulation
• Post tetanic facilitation
• Double brust stimulation (DBS 3,3)
CNS
• Monitoring the depth of anesthesia clinically by
signs and symptoms of light anesthesia:
• Tachycardia
• Hypertension
• Lacrimation
• Tachypnea, breath holding, coughing, bronchospasm.
• Eye movments
• Preserved reflexes
CNS

• EEG
• Patient evoked response
• Bispectral index
• Entropy – detection of abnormalities in EEG
at higher concentration of anesthetic agents
Evoked response
• Assessing the integrity of neuronal tissue during surgeries:
• Somatosensory evoked potential (SSEP)
• Any surgery that can compromise vascular supply of sensory
tract
• Auditory evoked potential (AEP)
• For procedures involving auditaory pathways
• Visual evoked potentials (VEP)
• Procedures involving visual tract
Monitoring blood loss
• Estimation of blood loss is done by weightining blood
soaked swabs, sponges, and estimation of blood loss
in suction bottle

• On an average
• Fully soaked swab means 20ml
• Fully soaked sponge means 100ml to 200 ml
• A fist of clots means 200 to 300 ml
Expired gas analysis

• There is a multigas analyzer which measures

concentration of anesthetic vapors like N2O
and inhalation agents
Thanks!
Any Q?