PHYSIOLOGIC MONITORING OF THE SURGICAL PATIENT

Elmer S. Jabagat, M.D FPCS, FPSGS, FPALES

Using measurements to guide therapy and follow its outcome.

Physiologic monitoring
• • • • • • • Hemodynamic Monitoring Respiratory Monitoring Gastric Tonometry Renal Monitoring Neurologic Monitoring Metabolic Monitoring Temperature Monitoring

Hemodynamic Monitoring
• Direct measurements A. Non Invasive: Sphygmomanometer B. Invasive:
– Arterial Catheterization – Central Venous Catheterization – Pulmonary Artery Catheterization

Derived Hemodynamic Parameters
– E.g. : cardiac index

Arterial Catheterization
Indicated whenever there is a need for continuous monitoring of blood pressure and/or frequent sampling of arterial blood:
– – – – shock of any etiology, acute hypertensive crisis, use of potent vasoactive or inotropic drugs, high levels of respiratory support (high intrathoracic pressure), – high-risk patients undergoing extensive operations, – controlled hypotensive anesthesia, – any situation in which any of the factors affecting cardiac function is rapidly changing. This is particularly true in patients with shock.
..\A-Line or Intra-Arterial Catheters.htm

Measured and derived hemodynamic parameters

RESPIRATORY MONITORING
• Ventilation monitoring
– Lung volumes
• Tidal volume (VT) • Vital capacity • Minute volume • Dead space

– Pulmonary mechanics : Inspiratory pressure

Lung compliance

Spirometer

RESPIRATORY MONITORING
• Gas monitoring
– Blood gas analysis – Capnography – Pulse oxymetry – Continuous mixed venous oxymetry

Pulse Oximetry

Gastric monitoring
• Gastric tonometry
•A relatively noninvasive monitor of the adequacy of aerobic metabolism in organs whose superficial mucosal lining is extremely vulnerable to low flow and hypoxemia and in which blood flow is sacrificed first in both shock and the systemic inflammatory response syndrome. •The gastrointestinal tract therefore will display metabolic changes before other indices of oxygen utilization.

Gastric monitoring
• Semi-permeable balloon connected to a sampling tube • Inserted trough the nose and pharynx, esophagus and stomach

..\Gastric Tonometry The Hemodynamic Monitor of Choice (Pro) -- Heard 123 (5 S Chest.htm

Renal Monitoring
• The primary reason for monitoring renal function is that the kidney serves as an excellent monitor of the adequacy of perfusion • To prevent acute parenchymal failure. • Renal function monitoring is helpful in predicting drug clearance and proper dose management

Renal Monitoring
1. Glomerular function tests
• • • Blood urea nitrogen Serum Creatinine Creatinine clearance ( derived measurement)

Renal Monitoring
• Serial determination of creatinine clearance is currently the most reliable method for clinically assessing GFR and the most sensitive test for predicting the onset of perioperative renal dysfunction.
Ccr = Ucr × V / Pcr × 1.73 / BSA Ucr = urinary creatinine concentration, mg/dL V = urinary volume flow, mL/min Pcr = plasma creatinine concentration, mg/dL BSA = body surface area, m2 Clearance results are expressed as milliliters per minute per 1.73m2.

Renal monitoring
• Tubular function tests
Tests that measure the concentrating ability of the renal tubules are used primarily in the differential diagnosis of oliguria to differentiate a prerenal cause unresponsive to judicious fluid therapy from intrinsic renal failure due to tubular dysfunction.

Tubular function tests

Neurologic monitoring
• • • • Intracranial pressure monitoring EEG Transcranial doppler Jugular venous oxymetry

Intracranial pressure monitoring

Noninvasive Intracranial Pressure Monitoring

EEG
• The electroencephalogram (EEG) reflects spontaneous and ongoing electrical activity recorded on the surface of the scalp. • Intraoperative EEG recording has been used primarily for monitoring the adequacy of cerebral perfusion during carotid endarterectomy. • Other procedures in which EEG recording has been used include cerebrovascular surgery, open heart surgery, epilepsy surgery, and induced hypotension for a variety of surgical procedures

Transcranial doppler
• Used to monitor cerebral blood flow. • Employs the Doppler principle to record the blood flow velocity in the basal cerebral arteries and can provide valuable information regarding the integrity of the intracranial circulation. • TCD also may detect vasospasm following spontaneous or traumatic subarachnoid hemorrhage and can help identify hyperemic or low-flow states

TCD

Jugular venous oxymetry
• Jugular venous oximetry is an invasive method of continuously monitoring jugular venous bulb oxyghemoglobin saturation (SjvO2). • Changes in SjvO2 provide a measure of the relationship between total cerebral blood flow and total cerebral oxygen consumption

Jugular venous oxymetry
• Jugular venous oximetry offers the potential to minimize secondary insults after severe head injury by facilitating recognition of cerebral ischemia. • Other applications include monitoring during neurosurgical procedures, carotid endarterectomy, and cardiopulmonary bypass

Metabolic monitoring
• Assessment of caloric requirements
– Harris Benedict equation (BEE)
Men: 66.47 + (13.75 × W) + (5.00 × H) - (6.76 × A) =BEE kcal/day Women: 65.51 + (9.56 × W) + (1.85 × H) -(4.68 × A) = BEE kcal/day where W = body weight, kg H= height, cm A = age, years

Metabolic monitoring
• Nutritional status
– Daily weight – Skin fold tests – Arm circumference

Metabolic monitoring
• Assessment of Oxygen consumption
– cardiac output times arterial oxygen content and oxygen consumption (normally about 150 mL/min/m2) assess oxidative metabolism.

Temperature monitoring
Temperature, along with heart rate, blood pressure, and respiratory rate, remains one of the traditional four cardinal vital signs

Temperature monitoring
• Core temperatures, which are relatively resistant to external influences, more accurately reflect the mean temperature of the body's vital organs. • Core temperature can be measured by placing a thermistor probe into either the esophagus or the rectum.

Temperature monitoring
• Three devices are available commercially for bedside measurement of core temperature in ICU patients:
1. Pulmonary artery thermistor catheters, 2. urinary bladder thermistor catheters 3. infrared auditory canal probes.

Temp Scan Instant Ear Thermometer

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