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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