MONITORING DURING ANESTHESIA

BY DOCTOR NASRULLAH KHAN MBBS FCPS

INTRODUCTION
In modern anesthesia very potent drugs are being used and awareness of patients about their care has put the patient and anesthetist at risk of various complications therefore monitoring has become an essential aspect of anesthesia care. The effective monitoring reduces the potential for poor outcomes that may follow anesthesia by identifying derangements before they result in serious or irreversible injury. Electronic monitors also improve physician's ability to respond because he or she is able to make repetitive measurements at higher frequencies than humans and do not fatigue or become distracted. Monitoring devices potentially increase the specificity and precision of clinical judgments.

. 2005.STANDARDS OF MONITORING • Two standards for basic anesthetic monitoring have been established by the American Society of Anesthesiologists (ASA) in 1986 and reaffirmed on October 25.practice. • These standards have emphasized the evolution of technology . clinical judgment and experience .

• These standards apply to all anesthesia care. except in emergency circumstances. (general anesthesia. where appropriate life support measures take precedence. . regional anesthesia and monitored anesthesia care) • No anesthetic procedure should be started without strictly observing these standards prior to operation.

and monitored anesthesia care to monitor the patient continuously and modify anesthesia care based on clinical observations and the responses of the patient to dynamic changes resulting from surgery or drug therapy. .STANDARD 1 • Standard I requires qualified personnel to be present in the operating room during general anesthesia. regional anesthesia.

EtCO2(Capnography) . circulation. ventilation. ECG. Oxygen saturation (Pulse oximetry) Blood Pressure (Non-invasive). and temperature and specifically mandates to monitor the following Pulse .STANDARD 2 Standard II focuses attention on continually evaluating the patient's oxygenation.

However in complicated cases more extensive monitoring may be required. Temperature. Cardiac output Pulmonary artery pressure. Renal functions Muscle relaxation Depth of anesthesia . Central venous pressure. Blood pressure (Invasive).

PULSE OXIMETRY • Pulse oximetry is a technique which measure pulse and oxygen saturation non invasively. toe. earlobe. A sensor containing light sources (two or three lightemitting diodes) and a light detector (a photodiode) is placed across a finger. .1. It combines the principles of oximetry and plethysmography . or any other perfused tissue that can be transilluminated.

• Oximetry depends on the observation that oxygenated and reduced hemoglobin differ in their absorption of red and infrared light (Lambert–Beer law). • Oxyhemoglobin (HbO2) absorbs more infrared light (960 nm). . whereas deoxyhemoglobin absorbs more red light (660 nm) which is analyzed by spectrophotometry.

. • These are particularly useful in children and in compromised patient having lung disease or cardiac problems.or special anesthetic technique (e g. one-lung anesthesia) also make it very essential.• Pulse oximeters are mandatory for almost all types of anesthetics including even moderate sedation. • The nature of the surgical procedure (chest surgery) .

skin pigmentation and anemia can interfere with actual reading.CONDITION OF LUNGS.hypotension. • CarboxyHb . O2 CARRYING CAPACITY OF BLOOD AND but does not give exact information about adequate ventilation so that the severe hypercarbia can develop without any alarm. PERFUSION OF TISSUES .• ALTOUGH OXIMETRY HELPS IN FINDING PROBLEMS WITH O2 SUPPLY . discoloration of nails.Met Hb .

from where it is excreted by ventilation. • Therefore capnography gives not only the information about adequate ventilation but also about all the mechanism involved in production and excretion of CO2.CAPNOGRAPHY • Capnography is measurement of end-tidal CO2 (ETCO2) which rely on the absorption of infrared light by CO2.2. . • As we know that CO2 is produced at cellular level when carbohydrates combine with O2 and then is carried out by the blood to lungs .

There is no contraindication.Ventilation can be monitored by observing the rate of respiration. pattern of breathing and auscultation of the breath sounds but capnogrphy has no match. • Although .• The various pattern of capnography gives lot of information about the different complication of anesthesia or surgical procedure. which is a major complication of sitting craniotomies. .. A rapid fall of ETCO2 is a sensitive indicator of air embolism.

Normal spontaneous breathing. . • B.Examples of capnograph waves A. Normal mechanical ventilation.

Exhausted CO2 absorbent produces an inhaled CO2 concentration greater than zero.Examples of capnograph waves • G. .

Examples of capnograph waves • H. Double peak for a patient with a single lung transplant. .

CAPNOGRAPHY VS OXIMETRY • OXYGEN AIR ---------LUNGS------BLOOD------TISSUES(CELLS) DETECTED BY OXYGEN PROBE • CARBON DIOXIDE TISSUE(CELL)------BLOOD------LUNGS------AIRWAYS (O2+CHO) DETECTED BY CO2 SENSOR .

There is no contraindication. ischemic changes. rhythm. .ELECTROCARDIOGRAPHY • Electrocardiography (ECG) should be started in all patients undergoing surgery before induction of anesthesia. • This gives lot of information about heart rate. and conduction defects in heart.3.

SOME COMMON ECG TRACINGS • Sinus normal rhthym • Sinus tachycardia • Sinus bradycardia .

• Atrial flutter • Atrial fibrillation • Ventricular tachycardia • PVCs .

• Ventricular fibrillation • Ventricular asystole .

The techniques and frequency of pressure determination depend on the patient's condition and the type of surgical procedure. no matter how "trivial. An oscillometric blood pressure measurement every 3–5 min is adequate in most cases." is an absolute indication for arterial blood pressure measurement.4. .BLOOD PRESSURE Non –invasive Blood Pressure Monitoring The use of any anesthetic.

Induced hypotension.End-organ disease necessitating precise beat-to-beat blood pressure regulation.• Invasive Blood Pressure Monitoring Arterial-Line is Indicated for invasive arterial blood pressure monitoring for following purposes. 1. . Anticipation of wide blood pressure swings. 2. and the need for multiple arterial blood gas analyses. 3.

Central venous pressure Central venous pressure is measured to see the status of body fluids and cardiac capability to maintain circulation. Aspiration of air emboli. . 3. Gaining venous access in patients with poor peripheral veins. If these occur during surgery.5. Central venous pressure (CVP). Administration of fluid to treat hypovolumia and shock. 4. The central venous catheter is passed for monitoring of 1. 2.

Fungating tricuspid valve vegetations. because of the possibility of unintentional carotid artery puncture. . 3. Receiving anticoagulants 4.Contraindications 1. Renal cell tumor extending into the right atrium 2. who have had an ipsilateral carotid endarterectomy.

the ASA concludes that the appropriateness of PAC use depends on the combination of risks associated with the patient. and the setting . the operation.therefore it is indicated in cardiac surgery only.6.Pulmonary artery catheterization • Although the effectiveness of pulmonary artery catheter (PAC) monitoring remains largely unproven in many groups of surgical patients. .

less than 15 min).7.Temperature • Temperature of every patient undergoing general anesthesia /spinal anesthesia should be monitored except very brief procedures (eg. • Esophageal probe or skin probe can be used for this purpose. .

Spinal anesthesia . 2. renal failure. 4. 5. congestive heart failure. shock. 3.8. advanced hepatic disease. Prolonged surgery 6.Urine output • Insertion of a urinary catheter is indicated in patients with 1.

Aortic or renal vascular surgery. 3. or procedures in which large fluid shifts are expected. craniotomy. Cardiac surgery. 2. Patients having difficulty in passing urine in recovery room after general or regional anesthesia. major abdominal surgery.• Catheterization is routine in some surgical procedures such as 1. Requiring intra operative diuretic administration 4. .

Peripheral nerve stimulator • Muscle are paralyzed during anesthesia for various surgical cases. Especially during neurosurgery and eye surgery where accurate level of relaxation is mandatory all the time throughout procedure. and the nature of surgery. Muscle relaxation is required to be monitored with help of nerve stimulator because of the variation in patient sensitivity to neuromuscular blocking agents. .9.

• To locate nerves to be blocked by regional anesthesia.• Nerve stimulator is also used in assessing paralysis during rapid-sequence induction or during continuous infusions of short-acting muscle relaxants . • To diagnose type and degree of muscle block during prolonged apnea .

I . . For this purpose various methods were used but without rewarding results. Recently a new method of assessing depth of anesthesia during operation has been introduced which has encouraging result.S).Bi spectral index scale Now a days awareness during anesthesia has become a challenging problem for the anesthetist especially in emergency cases when patient is not completely fit for anesthesia and therefore relatively light anesthesia is indicated . It is an advanced form of electroencephalography and is known as BI SPECTRAL INDEX SCALE (B .In such situation it becomes mandatory to assess the exact level of depth of anesthesia.10.

40–65 have been recommended for general anesthesia B I S I___I___I___I___I___I___I___I__ I 100 90 80 70 60 50 40 30 20 AWAKE SEDATION ANESTHESIA CORTICAL SILENCE . data measured by EEG are taken through a number of steps to calculate a single number that correlates with depth of anesthesia / hypnosis.To perform a bi-spectral analysis. BIS values of 65–85 have been advocated as a measure of sedation.

facilitating a faster wake-up time and perhaps a shorter stay in the recovery room.• The use of Bispectral analysis may help in reducing the chances of awareness during anesthesia. . • But unfortunately it is effective only in conventional form of general anesthesia and not in Ketamine anesthesia. an issue that is important to the public. • It may also reduce resource utilization because less drug is required to ensure amnesia.

.11.Measurement of anesthetic agent concentraion • Concentration of anesthetic agent in the end tidal air is also measured to assess the level of anesthesia depth and to avoid the dangerous side effects of strong volatile anesthetic agents.

Arterial blood gases and electrolytes are measured to find out acid base disorders and electrolyte disturbances during operation.Blood chemistry • Blood samples are sent to laboratory for measurement of Hb % to assess blood loss during surgery.12. .

.CONCLUSION • Monitoring during anesthesia has revolutionized field of anesthesia and use of very potent drugs has become possible without serious complications. • Human brain has no substitute therefore presence of qualified person has been put as standard 1 of monitoring.

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