MONITORING in Anaesthesia and Intensive Care

Prof. Serban Bubenek MD

Monitoring in Anaesthesia
and Intensive Care

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 Monitoring: A Definition
• ... interpret available clinical data to help
recognize present or future mishaps or
unfavorable system conditions

• ... not restricted to anesthesia

(change “clinical data” above to “system data” to apply to
aircraft and nuclear power plants)
 What is monitoring?
• Physiologic parameter & Patient safety parameter

• Clinical skills & Monitoring equipment

• Data collection, interpretation, evaluation, decision

• Problem seeking, Severity assessment, Therapeutic

assessment, Evaluation of Anesthetic interventions
 Patient Monitoring and Management
Involves …
• Things you measure (physiological measurement, such as
BP or HR)
• Things you observe (e.g. observation of pupils)

• Planning to avoid trouble (e.g. planning induction of

anesthesia or planning extubation)
• Inferring diagnoses (e.g. unilateral air entry may mean
endobronchial intubation)
• Planning to get out of trouble (e.g. differential diagnosis
and response algorithm formulation)
 Level of monitoring
• Routine / Specialize / Extensive

• Non-equipment / Non-invasive / Minimally invasive

/ Penetrating / Invasive / Highly invasive

• Systematic
– Respiratory / Cardiovascular / Temperature/ Fetal
– Neurological / Neuro-muscular / Volume status & Renal

• Standards for basic intraoperative monitoring ( ASA)

 Standards for basic intraoperative monitoring
( ASA : American Society of Anesthesiologists)
Standard I
– Qualified anesthesia personnel shall be present in the room throughout the
conduct of all :
- General Anesthesia
- Regional Anesthesia
- Monitored Anesthesia Care

Standard II
During all anesthetics, the patient’s :
– Respiratory (ventilation, oxygenation)
– Circulation shall be contiously evaluated
– Temperature
 Monitoring in Anesthesia
OBJECTIVES:

1.Guidelines to the practice of anesthesia and patient monitoring

2. Elements to monitor
(Anesthesia depth, Oxygenation, Ventilation, Circulation, Temperature)
2.1. ECG
2.2. Pulse Oximetry ( Function, Values, Limitations)
2.3. Blood Pressure (methods, indications, limitations, Insertion sites,
values)
2.4. Central venous line and pressure (methods, indications, limitations,
Insertion sites and it's advantages, Complications, values) 8
 Monitoring in Anesthesia
2.5. Capnography and EtCO2 (Uses, Measurement, values, factors
affecting EtCO2)
2.6. Cyanosis
2.7. The oxyhemoglobin dissociation curve (interpretation, causes of Left and
right shifting , key values, O2-Content of Blood)
2.8. Temperature ( Methods, Values, sites)

3. Normal values for a healthy adult undergoing anesthesia

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 Guidelines to the practice of anesthesia and patient
monitoring:
Monitoring in the Past

1. Visual monitoring of
respiration and overall
clinical appearance

2. Finger on pulse

3. Blood pressure
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 Harvey Cushing
Not just a famous neurosurgeon …
but the father of anesthesia monitoring

• Invented and popularized the anesthetic chart

• Recorded both BP and HR

• Emphasized the relationship between vital signs and

neurosurgical events
( increased intracranial pressure leads to hypertension and bradycardia )
 Guidelines to the practice of anesthesia and
patient monitoring:

1. Qualified anesthesia personnel

shall be present in the room throughout the conduct of :
- all general anesthetics
- regional anesthetics
- monitored anesthesia care

2. A completed pre-anesthetic checklist.

(history, physical exam, lab investigations, allergy, NPO policy)

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 Guidelines to the practice of anesthesia and patient
monitoring:
3. An anesthetic record.
- in general anaesthesia, regional anesthesia, or monitored IV conscious
sedation HR and BP should be measured every 5 min.
- also time, dose and route of drugs and fluids should be charted

4. During all anesthetics, the patient’s

- oxygenation
- ventilation
- circulation shall be continously evaluated !
- temperature

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 MONITORING

HR

O2 sat

RR

BP Temp

MAP 14
 Elements to Monitor :
I. Anesthetic Depth:
• Patients with local or regional anesthesia provide verbal feedback regarding well being.
• Onset of general anesthesia signaled by lack of response to verbal commands, in addition to
loss of blink reflex to light touch.
• Monitoring hypnosis
- electroencefalography (EEG)
- Newer methods (EEG based): - bispectral index(BIS) ( desired values 45 – 60)
- Entropy
• Inadequate anesthesia ( inadequate low level) can be signaled by :
- Facial grimacing or movement of arm or leg.
- but with muscle relaxants ( fully paralysis), it can be signaled by : Hypertension, tachycardia,
tearing or sweating.
-
• Excessive anesthesia can be signaled by :
- cardiac depression: bradycardia, and Hypotension.
- And also may result in hypoventilation, hypercapnia and hypoxemia when muscle relaxants
is not given
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-
 Elements to Monitor :
II. Oxygenation:
• Clinically, monitored by patient color ( with adequate
illumination ) and pulse oximetry.
• Quantitavely monitored by using oxygen analyzer, equipped
with an audible low oxygen concentration alarm.

III. Temperature
• Continuous temperature measurements monitoring is
mandatory if changes in temperature are anticipated or
suspected.

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 Elements to Monitor :
IV. Circulation:
• Clinically, monitored by pulse palpation, heart auscultation,
monitoring intra-arterial pressure (oximetry), central venous
pressures (CVP) or advanced techniques
• Quantitavely using ECG signals and arterial blood pressure
measurements every 5 min.
V. Ventilation
• Clinicaly, monitored through a correctly positioned
endotracheal tube, also observing chest excursions, reservoir
bag displacement, and breath sounds over both lungs.
• Quantitavely by ETCO2 analysis, equipped with an
audible disconnection alarm.
• Arterial blood gas analysis for assessing both oxygen and
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ventilation.
 Monitoring: Electrocardiogram ECG:

• A 3 or 5 lead electrode system is used for ECG monitoring in the OR.

• The 3 lead system has electrodes positioned on the right arm, left arm and chest
position. ( placed in the left anterior axillary line at the 5th interspace ).
Lead II is usually monitored by this system.

• The 5 lead system adds a right leg and left leg electrodes, which allows
monitoring D1, D2, D3, AVR, AVL, AVF and V5.

• II and V5 very important !

• ST segment

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 Monitoring: Electrocardiogram ECG:

• Identification of P waves in lead II and it’s association with the QRS

complex is useful in distinguishing a sinus rhythm from other
rhythms.

• Analysis of ST segment is used as an indicator of MI. ( Dep.-ischemia

/ elev.-infarction )

• Over 85% of ischemic events can be detected by monitoring ST

seg. of leads II and V5.

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 Monitoring:Pulse Oximetry:

• Allows beat to beat analysis of oxygenation.

• Depends on differences in light absorption between oxyHb and deoxyHb.

• Red and Infra-red light frequencies transmitted through a translucent

portion. (finger-tip or earlobe)

• Microprocessors then analyze amount of light absorbed by the 2

wavelengths, comparing measured values, then determining concentrations
of oxygenated and deoxygenated forms. (oxy- and deoxy-)
 PULSEOXIMETRY is for OXYGENATION
Principle : Spectrophotometry & Plethysmography

• relies on the differing absorption of light, at different wavelengths by the various

states of haemoglobin
- HbO2 has a higher absorption at 940 nm (blue light)
INFRARED

- Hb has a higher absorption at 660 nm (red light)

• the light signal following transmission through

the tissues has a pulsatile component

-
- two LEDs : one emitting red light (660 nm) and the
other a blue light (940nm) on the finger nail

- on the other side of the finger : photo sensor

(photocell) detects the transmitted light

- the LEDs are switched on and off at 30 Hz to detect

the cyclical changes in the signal due to pulsatile
arterial blood flow

- by calculating the absorption at the two

wavelengths the processor can compute the
proportion of haemoglobin which is oxygenated

CHbO2
S pO2 
CHbO2  CHb
 Pulse oximeters measure:
1. The oxygen saturation of haemoglobin in arterial blood
- SpO2 is a measure of the average amount of oxygen bound to each
haemoglobin molecule

- Haemoglobin is a compound of iron (haem) and globin chains.

- Each globin chain is linked to one atom of iron, each of which can carry 4
molecules of oxygen, and as each molecule of oxygen contains two atoms of
oxygen (O2), each haemoglobin molecule can carry 8 atoms of oxygen !

This makes haemoglobin a very efficient means of oxygen transport: each gram of
haemoglobin can carry 1.36ml of oxygen.

2. The pulse rate - in beats per minute, averaged over 5 to 20

seconds.
CaO2 = ( 1,37 x Hb x SaO2) + ( 0,0031 x PaO2 )
 PAY ATTENTION !
• SpO2 correlates with PaO2 as in Oxygen-Hemoglobin dissociation curve

- moderate hypoxemia
- mixed venous oxygen saturation
- P50 = 27 mm.Hg.
 The oxyhemoglobin dissociation curve
Key Values:
a. At PO2 100 mmHg, Hb 100% saturation.
b. At PO2 40 mmHg, Hb 75% saturation.
c. At PO2 27 mmHg, Hb 50% saturation.
.
 The oxyhemoglobin dissociation curve

• It is a sigmoid curve that describes the relationship between oxygen tension

(PaO2) and binding (SpO2).

• When PaO2 is low, the hemoglobin affinity to oxygen falls rapidly ,

explaining the sharp sloping .(PaO2< 60 mmHg)
The oxyhemoglobin dissociation curve
• A decrease in PaO2 of less than 60 mmHg (corresponding to SpO2
90 %) results in a rapid fall in the oxygenation saturation.
• The lowest acceptable O2 saturation level is 90%.
Left And Right Shifts of the
Oxyhemoglobin Dissociation Curve
Right Left
Decreased affinity of Hb for O2. Increased affinity of Hb for O2.
Causes: Causes:
•Inc. PCO2 •Dec. PCO2
•Hyperthermia •Hypothermia
•Acidosis •Alkalosis
•Increased altitude •Fetal hemoglobin
•Increased 2,3-DPG •Decreased 2,3-DPG
•Sickle Cell Anemia •Carboxyhemoglobin
•Inhalational anesthetics •Methemoglobin
 A pulse oximeter is affected by :

• ambient light
• shivering

• abnormal haemoglobins
( carboxyhaemoglobin, methaemoglobin, dyes as methylene blue )

• pulse rate and rhythm

• vasoconstriction
• poor tissue perfusion ( shock, low CO, cold extremities )

•NOT affected by : dark skin or anaemia.

 Cyanosis:
• Defined as the presence of 5 g./dL of deoxygenated hemoglobin
(deoxy Hb).

– i.e. Hb level = 15 g/dL, 5 g/dL release O2 which leaves 10 g/dL of

oxyhemoglobin

– SaO2 = OxyHb / (OxyHb + DeoxyHb) = 10 / (10 + 5) = 66%

– SaO2 of 66% corresponds to PaO2 of 35mmHg. !

• In anemic patients the oxygen tension at which cyanosis is

detectable will be even lower.
– i.e. Hb level = 10 gm/dL, 5 gm/dL release O2
– SaO2 = OxyHb / (oxyHb + DeoxyHb) = 5 / (5 + 5) = 50%

– SaO2 of 50% corresponds to PaO2 of only 27 mmHg. !!!!!

A pulse oximeter gives no information about :

•The oxygen content of the blood

(CaO2= SaO2x1,36xHb) + (PaO2 x 0,0031)
•The amount of oxygen dissolved in the blood
•The respiratory rate or tidal volume i.e. ventilation !!!!

•The cardiac output or blood pressure ?

 Monitoring: Blood Pressure BP:
o Methods of BP measurement:
1. Simplest method of BP measurement,
estimating the SBP, is by palpating the return
of arterial pulse as cuff is deflated (Riva-
Rocci).
2. auscultation of the Kortokoff sounds on deflation
(providing both SBP and DBP)
Mean Arterial Pressure
MAP = DBP + 1/3(SBP – DBP)
MAP = ( SBP + 2 DBP ) / 3
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 MEASUREMENT OF ARTERIAL PRESSURE

• INDIRECT measurement (non-invasive)

- signals generated by the occlusion of a major artery using a cuff
- gives not continous but intermittent measurements

- palpation method ( Riva Rocci)

- auscultation of the Korotkoff sounds
- osccilometry method

• DIRECT measurement (invasive and continous)

o Indirect Methods of BP measurement (1)

1. Riva Rocci: simplest method of BP measurement, estimating only

the SBP, is by palpating the return of arterial pulse as cuff is
deflated.

2. Auscultation of the Korotkoff sounds (1905)

on deflation created by the turbulent blood flow in the artery
(providing both SBP and DBP)
Mean Arterial Pressure (MAP) = DBP + 1/3(SBP – DBP)
 Indirect Methods of BP measurement (2)
3. OSCCILOMETRY
- a microprocessor controlled oscillometer. DINAMAP
- a pressure transducer that digitalizes signals ( microprocesor).
- rapid, accurate (± 9 mmHg) measurements of SBP, DBP, MAP and HR

- SAP corresponds to the onset of rapidly increasing oscillations

- MAP corresponds to the maximal oscillation at the lowest cuff pressure
- DAP corresponds to the onset of rapidly decreasing oscillations

LIMITATIONS:
- tendency to overestimate at low pressures and underestimate at high pressures
- errors : movements, arrhythmias or BP fluctuations
- compressive peripheral nerve injuries (repeated measurements )
 Cuff Size
• Too small cuff will result in false high blood pressure reading

• Too large cuff will result in false low blood pressure reading

f
r
o
m
 DIRECT Measurement of the BP
• invasive : catheter into the artery

METHODS

1. open Liquid column method (obsolete) , measures only MAP

13.4 cm. H2O = 10 mm.Hg.

2. Liquid manometers (obsolete)

3. Electromechanical transducers :
- conversion of mechanic signal into an electric signal
- and then electronically converted and displayed as :

SAP,DAP and MAP.

 Electromechanical - TRANSDUCERS

• The diaphragm :
- is moved by arterial pulsations which push the saline column
- should be thin, small and rigid !

• Transducers :

- based upon strain gauge principle : stretching (by PRESSURE ) a wire or

silicone crystal changes its electrical resistance

- connected to a wheatstone bridge circuit : so that the voltage output is

proportionate to the pressure applied it
 Monitoring: Blood Pressure BP:
o Methods of BP measurement:
4. Invasive BP measurements.
(Arterial BP):
Indications:
– Rapid moment to moment BP changes
– Frequent blood sampling
– Major surgeries (cardiac, thoracic, vascular)
– Circulatory therapies: vasoactive drugs, deliberate
hypotension
– Failure of indirect BP: burns, morbid obesity
– Sever metabolic abnormalities
– Major trauma
The radial artery at the wrist is the most
common site for an arterial catheter.
Alternatives are femoral, brachial and
dorsalis pedis. 39
 Central Venous line and Pressure (CVP)

• Catheter inserted into the SVC providing an estimate of

the right atrial and ventricular pressures.

• Serial CVP measurements are more useful than a single

value in order to assess blood volume, venous tone and
right ventricular performance. HR, BP and CVP
response to a volume infusion (100 – 500 ml) is also a
useful test of right ventricular performance.

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 Central Venous line and Pressure (CVP)
• Indications:
– CVP monitoring provides Right Atrial and Right
Ventricle pressures

– Advanced Cardiopulmonary disease + major

operation

– Secure vascular access for drugs

– Secure access for fluids + traumatic pts

– Aspiration of entrained air: sitting craniotomies

– Inadequate peripheral IV access

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 Central Venous Line:
PERFORMANCE of Right Internal Jugular Vein
• Internal jugular (Int. Jug.) vein lies in groove
between sternal and clavicular heads of
sternocleidomastoid muscle

• It is lateral and slightly anterior to carotid artery

• Aseptic technique, head down

• Insert needle towards ipsilateral nipple

• Seldinger method: 22 G finder; 18 G needle,

guide-wire, scalpel blade, dilator and catheter

• Observe ECG and maintain control of guide-wire

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• Ultrasound guidance; Chest-Xray post insertion.
 Advantages of Right Int. Jug. vein
• Consistent, predictable anatomic location
• Readily identifiable landmarks
• Short straight course to Superior Vena Cava
• Easy access for anesthesiologist at patient’s
head
• High success rate, 90-99%

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 Complications of Central lines (jugular):

• Bleeding
• Injury to surrounding
structures as carotid artery
• Pneumothorax
• Arrhythmia

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Central Venous line Alternative Sites
• Subclavian vein:
– Easier to insert versus Int. Jug. vein
– Better patient comfort v. Int. Jug.
– Higher Risk of pneumothorax- 2%

• External jugular:
– Easy to cannulate if visible.
– no risk of pneumothoroax,
– high risk or bleeding
– 20%: cannot access central circulation

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 Central Venous Pressure (CVP )
Monitoring
• Reflects pressure at junction of vena cava + RA
• CVP is driving force for filling RA + RV
• CVP provides estimate of:
– Intravascular blood volume
– RV preload
• Trends in CVP are very useful
• Measure at end-expiration
• Central Venous Pressure (CVP): 1-10 mmHg

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SWAN GANZ = PA CATHETER
 SWAN-GANZ catheter
Waveform during Insertion
PA CATHETER
PA CATHETER
• Zone III allows for
uninterrupted blood
flow and a continuous
communication with
distal intracardiac
pressures. (PAand PV
exceed Palv)
 PAC-Thermodilution

• The change of the blood’s temperature in is measured in the pulmonary artery

using the PAC thermistor

• The thermistor records the temperature change and the monitor electronically
displays a temperature/time curve.

• The CO is inversely proportional to :

- the temperature change
- the area under the curve
( PAC measures the Pulm.CO = Global CO if no intracardiac shunt )
MEASUREMENT OF BLOOD FLOW:
CARDIAC OUTPUT

The Nexfin HD
A truly non-
invasive CCO
monitor
 Potential Methods To Measure Cardiac Output

• Fick metdod
• Indicator dilution
• Pulse waveform ( pulse contour) methods
• ULTRASOUNDS ( 2D-Echo and Doppler techique)
• Bioimpedance

• ANGIOGRAPHY
• MRI
PULMONARY Thermodilution TRANSPULMONARY Thermodiution

• The pulmonary artery TD curve appears earlier and has a higher peak temperature than
the femoral artery TD curve.

• TP-TD is less invasive than P-TD, but does NOT give : SvO2 an PAP values !

,
 The Clinical USE of TP-TD

• Mainly : as a “ calibration method” for other

systems : PiCCO, LiDCO-Pulse CO

• PiCCO and LiDCO-Pulse CO are able after the initial calibration, to

measure in a continous manner
( beat by beat ) the C.O, using :

the Pulse Contour method

 The Pulse Contour method

1. CALIBRATED techniques
PiCCO
LiDCO – Pulse CO

2. NON-CALIBRATED techniques
Flow-Track VIGILEO
Nexfin
 CCO by the pulse contour method
The area under the systolic part of the AP waveform correlates :
- directly with Left Ventricular STROKE VOLUME
- inversely with aortic impedance

SV

• For calibrated techiques : the Aortic impedance is estimated from AP and CO pre-
measured values
( calibration : CO is ussualy measured by TP-TD)
PiCCO

Continous pulse contour analysis with intermittent TP-TD calibration.

Enables continuous hemodynamic monitoring using:

- femoral or axillary artery catheter
- central venous catheter
 LiDCO – Pulse CO
• the independent calibration technique is : Lithium indicator Dilution

• safe and minimally invasive : peripheral venous and arterial catheters

• The PulseCO algorithm used by LiDCO is based on pulse power derivation.

• Continuous, real-time cardiovascular monitoring

 Pulse Contour NON-CALIBRATED techniques

• Flow-Track VIGILEO
- only arterial line

• NEXFIN
- totally non-invasive
 BIOIMPEDANCE
• bio tissues (bone, muscle,blood, etc) have different electric proprieties
• blood is the most conductive tissue ( Na+ and Cl-)
• pulsatile modification of ITBV → Δ TB
Δ TB ~ Δ stroke volume

SV = K x (dZ / dt) / Zo x TEV

Δ TB is measured by : producing and transmiting electricity

( high υ = 70 kHz low A = 2,5 mA ) betwwen 2 pairs of electrodes
 Echocardiography for measuring the CO

• 2 D – method

• Doppler - method
 Ultrasounds (1.)
• US techniques can detect : the shape, size and movement of tissue
interfaces, especially soft tissues and blood (RBC)

• US are defined by :
- amplitude of oscillation (delta pressure : ambient to peak) dB
- the wavelength (distance between successive peaks)
- frequency (inversely proportional to wavelength, nr. of cycles / second )

• human ear can detect frequencies : 20-20,000 Hz.

• US have frequencies > 20,000 cycles /sec ( 20 KHz)
• diagnostic US uses frequencies in the range of 1-10 MHz.
 Ultrasounds (2.)
• Transducers :
- generate and sense US
- are made from ceramic materials able to transform mechanical energy (pressure) to
electrical energy and vice versa ( the piezoelectric effect )

- Transducers : generates ultrasound of the same frequency as the applied voltage

• Shorter wavelengths and higher frequencies improve the resolution of distance,

but tissue penetration is simultaneously reduced.

• Amplitude determines the intensity of the ultrasound beam and therefore the
sensitivity of the instrument.
 2-D Method
Principle

Stroke volume= End diastolic volume – End systolic volume

LV volumes estimated by Simpson’s method, which is the summation of
the volume of stacked cylinders within the LV at end-diastole and end-
systole

150 ml - 52 ml= 98 ml
 Doppler Effect (1)
• frequency of US waves reflected from a stationary object is the same as that
transmited

• frequency of transmitted US is altered as it is reflected from a moving object

there is an increase in the observed frequency of a signal when

the signal source approaches the observer

e.g. ambulance siren

 Doppler Effect - 3
• Doppler effect represented by:

V= _ΔF . c _
2 F0 cos θ

Where V = velocity of object

ΔF = frequency shift
c = speed of sound in medium (body tissue here)
F0 = frequency of emitted sound
cos θ = angle between sound wave and flow (RBC)

cos 90◦ = 0 so the US beam should be parallel to RBC

Maximum angle = 20◦
 Doppler Method
Principle
Flow (stroke volume)=Area x Velocity

CO=Stroke volume * Heart rate

Flow Velocity at LVOT
Area of left ventricular outflow tract
Pulsed wave Doppler at LVOT in apical
Obtain LVOT dimension in parasternal long axis view 5 chamber view

D=2.1 cm

Velocity time integral 25 cm

Simplified formula= (2.1cm)2 * 0.785
3.46cm 2 X 25cm = 87 cm3
 OESOPHAGEAL DOPPLER
Measurement of blood flow velocity in the descending aorta at
the tip of the flexible probe

4 MHz continuous or 5 MHz pulsed wave

CO (cardiac output)
SV (stroke volume)
FTc (corrected f low time)
PV (peak velocity)
MD (minute distance)
HR (heart rate)
 Capnography and EtCO2

• Capnometry: is the numerical measurement of CO2 concentration

during inspiration and expiration.

• Capnogram: refers to the continuous display of the CO2

concentration waveform sampled from the patient’s airway during
ventilation.

• Capnography: is the continuous monitoring of a patient’s

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capnogram.
 Capnography and EtCO2
• End-tidal CO2 monitoring is standard for all patients undergoing
GA with mechanical ventilation.

• It is an important safety monitor and a valuable monitor of the patient’s

physiologic status, and it has been an important factor in reducing
anesthesia-related mortality and morbidity.

• CO2 monitoring is considered the best method for verifying successful

intubation and extubation procedures.

• It helps in assessment of the adequacy of ventilation and an indirect

estimate of PaCO2.

• Also it aids in diagnosis of PE, recognition of a partial airway obstruction,

and indirect measurement of airway reactivity (bronchospasm).

• ETCO2 levels have also been used to predict outcome of resuscitation.

 Capnography and EtCO2
Measurement of ETCO2
• Sampling the patient’s respiratory gases near the airway.
• Using infra-red gas analysis or mass spectrometry on the values
and concentrations obtained.

• Provided that when sampling, inspired CO2 value should be near

zero. (i.e. ETCO2 value is a function of CO2 production, alveolar
ventilation and pulmonary circulation; excluding inspired CO2).
• During general anesthesia, with absence of ventilation perfusion
abnormalities, difference between PaCO2 and ETCO2 is about 5 mm
Hg (PaCO2 = 40 mmHg, ETCO2 = 35 mmHg)

• Increases or decreases in ETCO2 values maybe the result of

increases or decreases in production and elimination.
Capnography and EtCO2 Factors affecting ETCO2:
Increased ETCO2 Decreased ETCO2
Changes in CO2 Production
•Hyperthermia •Hypothermia
•Sepsis •Hypometabolism
•Thyroid storm
•Malignant Hyperthermia
•Muscular Activity
Changes in CO2 Elimination
•Hypoventilation •Hyperventilation
•Rebreathing •Hypoperfusion
•Partial airway obstruction •Embolism
•Exogenous CO2 absorption
(laparoscopy)
•Transient increases in ETCO2 may be noted after: IV bicarbonate
administration, release of extremity tourniquets, or removal of vascular cross-
clamps.
 Capnography and EtCO2
• Normal

• Esophageal 0 ! > 4 curves !

• Cardiac arrest bronhospasm

• Curare cleft spontaneous

•
exhausted CO2 absorber

• IMV

• Expiratory Valve

• Inspiratory valve

• Hyper and hypo VENTILATION

 Monitoring Temperature

Objective
 aid in maintaining appropriate body temperature
Application
 readily available method to continuously monitor
temperature if changes are intended, anticipated or
suspected
Methods
 thermostat
 temperature sensitive chemical reactions
 Monitoring Temperature

• Potential heat loss or risk of hyperthermia

necessitates continuous temperature
monitoring
• Normal heat loss during anesthesia averages
0.5 - 1 C per hour, but usually not more that 2 -
3C
• Temperature below 34C may lead to
significant morbidity
 Monitoring Temperature

• Hypothermia develops when thermoregulation

fails to control balance of metabolic heat
production and environment heat loss
• Normal response to heat loss is impaired
during anesthesia
• Those at high risk are elderly, burn patients
neonates, spinal cord injuries
 Monitoring Temperature

Hyperthermia Causes
• Malignant hyperthermia
• Endogenous pyroxenes (IL1)
• Excessive environmental warming
• Increases in metabolic rate secondary to:
– Thyrotoxicosis
– Pheochromocytoma
 Monitoring Temperature

Monitoring Sites
• Tympanic
• Esophagus
• Rectum
• Nasopharynx

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Normal values for a healthy adult undergoing
anesthesia
 Systolic Blood Pressure SBP 85 – 160 mmHg
 Diastolic Blood Pressure DBP 50 – 95 mmHg
 Heart Rate HR 50 – 100 bpm
 Respiratory Rate RR 8 – 20 rpm
 Oxygen sat. by oximetry SpO2 95 – 100 %
 End Tidal Carbon Dioxide tension ETCO2 33 – 45 mmHg
 Skin appearance warm, dry
 Color pink
 Temperature 36 – 37.5 OC
 Urine Production >= 0.5 ml.kg-1.min-1
 Central Venous Pressure CVP 1 – 10 mmHg
 Pulmonary Artery Pressure PAP (mean) 10 – 20 mmHg
 Pulmonary Capillary Wedge Pressure PCWP 5 – 15 mmHg
 Mixed venous oxygen saturation SvO2 75 %
 Cardiac Output CO 4.5 – 6 1.Min-1
Mean Arterial Pressure MAP 80 – 120 mmHg
*MAP = DBP + 1/3 ( SBP – DBP )
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THANK YOU

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THANKS for your attention !