Patient Monitoring

INTRODUCTION TO INTRODUCTION TO PATIENT MONITORINGPATIENT MONITORING

InIn

ANESTHESIA ANESTHESIA

PROF. AMIR B.CHANNA FFARCSPROF. AMIR B.CHANNA FFARCSKKUH, RIYADHKKUH, RIYADH

Monitoring: DefinitionMonitoring: DefinitionWord Monitor is from Word Monitor is from

MonereMonere means means warningwarning

... interpret available clinical ... interpret available clinical data to help recognize present or data to help recognize present or future mishaps or unfavorable future mishaps or unfavorable system conditionssystem conditions

... not restricted to anesthesia ... not restricted to anesthesia (change “clinical data” above to “system (change “clinical data” above to “system data” to apply to aircraft and nuclear power data” to apply to aircraft and nuclear power plantsplants))

WhyWhy monitoring anesthetized monitoring anesthetized patients ?patients ?

WhyWhy monitoring anesthetized monitoring anesthetized patients ?patients ?

• Anesthetic agents - cardiopulmonary depressants

• Homeostasis

• Patient’s response to (physio & pharma & Surgical) interventions

• Proper function of anesthetic equipment

• Anesthetic agents - cardiopulmonary depressants

• Homeostasis

• Patient’s response to (physio & pharma & Surgical) interventions

• Proper function of anesthetic equipment

Detecting Mishaps Using Detecting Mishaps Using MonitorsMonitors

1. Disconnection1. Disconnection

2. Hypoventilation2. Hypoventilation

3. 3. Esophageal intubationEsophageal intubation

4. Bronchial intubation4. Bronchial intubation

5. Circuit hypoxia5. Circuit hypoxia

6. Anesthetic 6. Anesthetic overdoseoverdose

7. Hypovolemia7. Hypovolemia

8. Pneumothorax8. Pneumothorax

9. Air Embolism9. Air Embolism

10. Hyperthermia10. Hyperthermia

11. Aspiration11. Aspiration

12. 12. Acid-base imbalanceAcid-base imbalance

13. 13. Cardiac dysrhythmiasCardiac dysrhythmias

14.14. IV drug overdose IV drug overdose

Source: Barash Handbook Source: Barash Handbook

These mishaps …

Patient Monitoring and Patient Monitoring and ManagementManagement

Involves …Involves …continual or continuouscontinual or continuous Things you measureThings you measure (physiological parameters & their (physiological parameters & their

measurement, such as BP or HR)measurement, such as BP or HR)

Things you observeThings you observe (e.g. observation of pupils)(e.g. observation of pupils)

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

anesthesia or planning extubation)anesthesia or planning extubation)

Inferring diagnosesInferring diagnoses (e.g. unilateral air entry may mean (e.g. unilateral air entry may mean

endobronchial intubation)endobronchial intubation)

Planning to get out of troublePlanning to get out of trouble (e.g. differential diagnosis (e.g. differential diagnosis

and response algorithm formulation)and response algorithm formulation)

WhatWhat should be monitored ? should be monitored ?WhatWhat should be monitored ? should be monitored ?

• CirculationCirculation (cardiovascular) (cardiovascular)

• VentilationVentilation (respiratory) (respiratory)

• OxygenationOxygenation (cardiorespiratory)(cardiorespiratory)

• Maintain adequate tissue Maintain adequate tissue perfusion with oxygenated perfusion with oxygenated bloodblood

• CirculationCirculation (cardiovascular) (cardiovascular)

• VentilationVentilation (respiratory) (respiratory)

• OxygenationOxygenation (cardiorespiratory)(cardiorespiratory)

• Maintain adequate tissue Maintain adequate tissue perfusion with oxygenated perfusion with oxygenated bloodblood

Monitoring in the Monitoring in the PastPast

Finger on the pulse

Monitoring in the Monitoring in the PastPast

Visual Visual monitoring of monitoring of respiration and respiration and overall clinical overall clinical appearanceappearance

Finger on pulseFinger on pulse Blood pressure Blood pressure

(sometimes)(sometimes)

Harvey Cushing Harvey Cushing Not just a famous neurosurgeon … Not just a famous neurosurgeon …

but the father of anesthesia but the father of anesthesia monitoringmonitoring Invented and popularized Invented and popularized

the anesthetic chartthe anesthetic chart Recorded both BP and HRRecorded both BP and HR Emphasized the relationship Emphasized the relationship

between vital signs and between vital signs and neurosurgical eventsneurosurgical events ( increased intracranial pressure leads ( increased intracranial pressure leads to hypertension and bradycardia )to hypertension and bradycardia )

Concept Development

CRRTInfusion Devices

Physiological Monitoring

Ventilation

Monitoring in the Monitoring in the PresentPresent

Standardized basic monitoring Standardized basic monitoring

requirements (guidelines) from the requirements (guidelines) from the ASA ASA

(American Society of Anesthesiologists),(American Society of Anesthesiologists),

CASCAS (Canadian Anesthesiologists’ Society)(Canadian Anesthesiologists’ Society)

and other national societiesand other national societies Many integrated monitors availableMany integrated monitors available Many special purpose monitors availableMany special purpose monitors available Many problems with existing monitors Many problems with existing monitors

(e.g., cost, complexity, reliability, (e.g., cost, complexity, reliability, artifacts)artifacts)

ASA Monitoring GuidelinesASA Monitoring Guidelines

STANDARD I

Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.

ASA Monitoring GuidelinesASA Monitoring Guidelines

STANDARD II

During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.

http://www.asahq.org/publicationsAndServices/standards/http://www.asahq.org/publicationsAndServices/standards/02.pdf02.pdf

““The The only indispensable monitor only indispensable monitor is the is the

presence, at all times, of a presence, at all times, of a physicianphysician or an or an

anesthesia assistant, under the immediate anesthesia assistant, under the immediate

supervision of an anesthesiologist, with supervision of an anesthesiologist, with

appropriate training and experience. appropriate training and experience.

Mechanical and electronic monitorsMechanical and electronic monitors are, at best, are, at best,

aids to vigilance. Such devices assist the aids to vigilance. Such devices assist the

anesthesiologist to ensure the integrity of the anesthesiologist to ensure the integrity of the

vital organs and, in particular, the adequacy of vital organs and, in particular, the adequacy of

tissue perfusion and oxygenation.”tissue perfusion and oxygenation.”

CAS Monitoring GuidelinesCAS Monitoring Guidelines

The following are The following are requiredrequired: : Pulse oximeterPulse oximeter Apparatus to measure Apparatus to measure blood pressureblood pressure, ,

either either directly ordirectly or noninvasively noninvasively ElectrocardiographyElectrocardiography CapnographyCapnography, when endotracheal tubes or , when endotracheal tubes or

laryngeal masks are inserted. laryngeal masks are inserted. Agent-specific anesthetic gas monitorAgent-specific anesthetic gas monitor, when , when

inhalation anesthetic agents are used. inhalation anesthetic agents are used.

CAS Monitoring GuidelinesCAS Monitoring Guidelines

The following shall be exclusively The following shall be exclusively available for each patient: available for each patient: Apparatus to Apparatus to measure temperaturemeasure temperature Peripheral nerve stimulatorPeripheral nerve stimulator, when , when

neuromuscular blocking drugs are used neuromuscular blocking drugs are used StethoscopeStethoscope — either precordial, — either precordial,

esophageal or paratracheal esophageal or paratracheal Appropriate Appropriate lighting to visualize lighting to visualize an an

exposed portion of the patient. exposed portion of the patient.

CAS Monitoring GuidelinesCAS Monitoring Guidelines

The following shall be immediately The following shall be immediately available: available:

Spirometer for measurement of tidal Spirometer for measurement of tidal volume. volume.

CAS Monitoring Guidelines CAS Monitoring Guidelines

Detecting Mishaps Using Detecting Mishaps Using MonitorsMonitors

1. Disconnection1. Disconnection

2. Hypoventilation2. Hypoventilation

3. 3. Esophageal intubationEsophageal intubation

4. Bronchial intubation4. Bronchial intubation

5. Circuit hypoxia5. Circuit hypoxia

6. Anesthetic 6. Anesthetic overdoseoverdose

7. Hypovolemia7. Hypovolemia

8. Pneumothorax8. Pneumothorax

9. Air Embolism9. Air Embolism

10. Hyperthermia10. Hyperthermia

11. Aspiration11. Aspiration

12. 12. Acid-base Acid-base imbalanceimbalance

13. 13. Cardiac dysrhythmiasCardiac dysrhythmias

14.14. IV drug overdose IV drug overdose

Source: Barash Handbook Source: Barash Handbook

These mishaps …

Detecting Mishaps with Detecting Mishaps with MonitorsMonitors

Pulse oximeterPulse oximeter Mass spectrometerMass spectrometer CapnographCapnograph Automatic BPAutomatic BP StethoscopeStethoscope SpirometerSpirometer Oxygen analyzerOxygen analyzer EKGEKG TemperatureTemperature

1,2,3,4,5,8,9,11,141,2,3,4,5,8,9,11,14

1,2,3,6,9,10,121,2,3,6,9,10,12

1,2,3,9,10,121,2,3,9,10,12

6,7,9,146,7,9,14

1,3,4,131,3,4,13

1,21,2

55

131310 10 Source: Source: Barash Barash

Handbook Handbook

… are detected using these monitors

Basic MonitoringBasic Monitoring CardiacCardiac: Blood Pressure, Heart Rate, ECG: Blood Pressure, Heart Rate, ECG ECGECG: Rate, ST Segment (ischemia), Rhythm : Rate, ST Segment (ischemia), Rhythm RespiratoryRespiratory: Airway Pressure, Capnogram, Pulse : Airway Pressure, Capnogram, Pulse

Oximeter, Spirometry, Visual CuesOximeter, Spirometry, Visual Cues TemperatureTemperature [pharyngeal, axillary, esophageal, etc.][pharyngeal, axillary, esophageal, etc.]

Urine outputUrine output (if Foley catheter has been placed) (if Foley catheter has been placed) Nerve stimulatorNerve stimulator [face, forearm] [face, forearm] (if relaxants used)(if relaxants used)

ETT cuff pressure ETT cuff pressure (keep < 20 cm H(keep < 20 cm H22O)O)

Auscultation Auscultation (esophageal or precordial stethoscope)(esophageal or precordial stethoscope)

Visual surveillanceVisual surveillance of the anesthesia workspace of the anesthesia workspace

and some exposed portion of the patientand some exposed portion of the patient

HowHow to monitor to monitor circulation?circulation?HowHow to monitor to monitor circulation?circulation?

• Palpation, auscultationPalpation, auscultation • Arrhythmia, ECGArrhythmia, ECG• Blood pressureBlood pressure

–Doppler ultrasound flow Doppler ultrasound flow detectordetector

–Automated oscillometric Automated oscillometric devicesdevices

• Palpation, auscultationPalpation, auscultation • Arrhythmia, ECGArrhythmia, ECG• Blood pressureBlood pressure

–Doppler ultrasound flow Doppler ultrasound flow detectordetector

–Automated oscillometric Automated oscillometric devicesdevices

How to monitor How to monitor oxygenation oxygenation ??How to monitor How to monitor oxygenation oxygenation ??

• Blood gas analysis Blood gas analysis (PaO(PaO22))

• Pulse oximetry (SaOPulse oximetry (SaO22))

• Oxy-hemoglobin saturationOxy-hemoglobin saturation• HemoximetryHemoximetry

–Oxy-hemoglobinOxy-hemoglobin

–Met-hemoglobinMet-hemoglobin

–Carboxy-hemoglobinCarboxy-hemoglobin

• Blood gas analysis Blood gas analysis (PaO(PaO22))

• Pulse oximetry (SaOPulse oximetry (SaO22))

• Oxy-hemoglobin saturationOxy-hemoglobin saturation• HemoximetryHemoximetry

–Oxy-hemoglobinOxy-hemoglobin

–Met-hemoglobinMet-hemoglobin

–Carboxy-hemoglobinCarboxy-hemoglobin

How to monitor How to monitor ventilationventilation ? ?How to monitor How to monitor ventilationventilation ? ?

• Arterial blood gasesArterial blood gases– PaCOPaCO22 ,PaO ,PaO22

• CapnographyCapnography– End-tidal COEnd-tidal CO2 2 Respiratory Respiratory

RateRate

• RespirometryRespirometry– Tidal volume, minute volumeTidal volume, minute volume

• Arterial blood gasesArterial blood gases– PaCOPaCO22 ,PaO ,PaO22

• CapnographyCapnography– End-tidal COEnd-tidal CO2 2 Respiratory Respiratory

RateRate

• RespirometryRespirometry– Tidal volume, minute volumeTidal volume, minute volume

CapnographyCapnographyCapnographyCapnography

• MetabolismMetabolism

• CirculationCirculation

• VentilationVentilation

• Anesthetic equipment Anesthetic equipment functionfunction

• Capnometer (no capnogram)Capnometer (no capnogram)

• Only one normal shapeOnly one normal shape

• MetabolismMetabolism

• CirculationCirculation

• VentilationVentilation

• Anesthetic equipment Anesthetic equipment functionfunction

• Capnometer (no capnogram)Capnometer (no capnogram)

• Only one normal shapeOnly one normal shape

Visual SurveillanceVisual Surveillance Anesthesia machine / workspace checkoutAnesthesia machine / workspace checkout Patient monitor numbers and waveformsPatient monitor numbers and waveforms Bleeding/coagulation Bleeding/coagulation (e.g., are the surgeons (e.g., are the surgeons

using a lot of suction or sponges? )using a lot of suction or sponges? ) Diaphoresis / movements / grimacesDiaphoresis / movements / grimaces Line quality Line quality ((is my IV reliableis my IV reliable?)?) Positioning safety reviewPositioning safety review Respiratory pattern Respiratory pattern (e.g. tracheal tug, (e.g. tracheal tug,

accessory muscle use etc.)accessory muscle use etc.)

Low Tech Patient Low Tech Patient MonitoringMonitoring

Manual blood pressure cuffManual blood pressure cuff Finger on the pulse and foreheadFinger on the pulse and forehead Monaural stethoscope Monaural stethoscope

(heart and breath sounds)(heart and breath sounds) Eye on the rebreathing bag Eye on the rebreathing bag (spontaneously (spontaneously

breathing patient)breathing patient) Watch respiratory patternWatch respiratory pattern Watch for undesired movementsWatch for undesired movements Look at the patient’s faceLook at the patient’s face

color OK? color OK? diaphoresis present?diaphoresis present? pupilspupils

Typical display. Perceptible output?

High Tech Patient High Tech Patient MonitoringMonitoring

Examples of Multiparameter Patient MonitorsExamples of Multiparameter Patient Monitors

High Tech Patient High Tech Patient MonitoringMonitoring

Some Specialized Patient MonitorsSome Specialized Patient Monitors

BIS Depth of Anesthesia Monitor

Evoked Potential Monitor

Transesophageal Echocardiography

Special MonitoringSpecial Monitoring Pulmonary artery linesPulmonary artery lines (Swan Ganz) (Swan Ganz) Transesophageal echocardiographyTransesophageal echocardiography Intracranial pressure (ICP) monitoringIntracranial pressure (ICP) monitoring Electrophysiological CNS monitoringElectrophysiological CNS monitoring Renal function monitoring (indices)Renal function monitoring (indices) Coagulation monitoring (e.g. ACT)Coagulation monitoring (e.g. ACT) Acid-base monitoring (ABGs)Acid-base monitoring (ABGs) Monitoring depth of anesthesia__BISMonitoring depth of anesthesia__BIS

AlarmsAlarms Purpose:Purpose: Alarms serve to alert Alarms serve to alert

equipment operators that some equipment operators that some monitored variable or combination monitored variable or combination of variables is outside some regionof variables is outside some region

Motivation:Motivation: recognition of limited recognition of limited attentiveness capability in humans, attentiveness capability in humans, even under good operating even under good operating conditionsconditions

Airway / Respiratory Airway / Respiratory AxisAxis

Correct ETT placementCorrect ETT placement ETT cuff pressureETT cuff pressure Airway pressureAirway pressure OxygenationOxygenation VentilationVentilation SpirometrySpirometry Pulmonary biomechanicsPulmonary biomechanics Airway gas monitoringAirway gas monitoring Clinical: Clinical: wheezing, crackles, equal air entry, wheezing, crackles, equal air entry,

color, respiratory pattern (rate, rhythm, depth, color, respiratory pattern (rate, rhythm, depth, etc.)etc.)

Circulatory AxisCirculatory Axis Cardiac outputCardiac output Input pressures (CVP, LAP)Input pressures (CVP, LAP) Output pressures (BP, PAP)Output pressures (BP, PAP) Pacemaker: rate, conductionPacemaker: rate, conduction Cardiac contractilityCardiac contractility Vascular resistances (SVR, PVR)Vascular resistances (SVR, PVR) Intracardiac shuntsIntracardiac shunts

Depth of Depth of AnesthesiaAnesthesia

Clinical SignsClinical Signs eye signseye signs

respiratory signsrespiratory signs

cardiovascular signscardiovascular signs

CNS signsCNS signs

EEG monitoringEEG monitoring

Facial EMG monitoring Facial EMG monitoring

(experimental)(experimental)

Esophageal contractility (obsolete)Esophageal contractility (obsolete)

CNS MonitoringCNS Monitoring Clinical: Clinical: sensorium, reflexes, “wake up test”sensorium, reflexes, “wake up test” Electroencephalography: Electroencephalography: raw EEG, compressed raw EEG, compressed

spectral arrays (CSA), 95% spectral edge, etc.spectral arrays (CSA), 95% spectral edge, etc. Evoked potentialsEvoked potentials (esp. somatosensory EPs) (esp. somatosensory EPs) Monitoring for venous air emboliMonitoring for venous air emboli Intracranial pressure (ICP) monitoringIntracranial pressure (ICP) monitoring Transcranial doppler studiesTranscranial doppler studies

(MCA flow velocity) (MCA flow velocity) (Research)(Research) Jugular bulb saturation Jugular bulb saturation (Research)(Research) Cerebral oximetry Cerebral oximetry (Research)(Research)

Relaxation AxisRelaxation Axis Clinical Signs +/- Nerve Clinical Signs +/- Nerve

StimulatorStimulator MechanomyographyMechanomyography ElectromyographyElectromyography Piezoelectric methodsPiezoelectric methods Special methods (e.g. DBS)Special methods (e.g. DBS)

Temperature MonitoringTemperature MonitoringRationale for useRationale for use detect/prevent hypothermiadetect/prevent hypothermia monitor deliberate hypothermia monitor deliberate hypothermia adjunct to diagnosing MHadjunct to diagnosing MH monitoring CPB cooling/rewarmingmonitoring CPB cooling/rewarming

SitesSites EsophagealEsophageal NasopharyngealNasopharyngeal AxillaryAxillary RectalRectal BladderBladder

Electrolyte / Metabolic Electrolyte / Metabolic AxisAxis

Fluid balanceFluid balance SugarSugar ElectrolytesElectrolytes Acid-base balanceAcid-base balance Nutritional statusNutritional status

Coagulation MonitoringCoagulation Monitoring

Clinical signsClinical signs PT / PTT / INRPT / PTT / INR ACTACT Platelet countsPlatelet counts Factor assays Factor assays TEGTEG

Monitoring Neuromuscular Function

• Mechanomyography

– Measures tension– Resting Tension Reg’d– Cumbersome setup– Gold standard

Monitoring Neuromuscular Function

• Electromyography

– Cpd. AP represents sum of motor units

– More muscles accessible– Good correlation with

tension

Monitoring Neuromuscular Function

• Accelerometryf = m X a

No resting tension reg’d

Again reliable !

Monitoring Neuromuscular Function

• Kinemyography– Datex M-NMT– Motion sensor ?

– Reliability?

Hemmerling and Donati A&A 95,1826-27,2003

Monitoring Neuromuscular Function

Phonomyography

• Detection of muscle contraction with a microphone

• Research only• Corrugator supercilii-

same sensitivity as diaphragm

Monitoring Neuromuscular Function

• REQUIREMENTS OF A STIMULATOR

– Multiple modes of stimulation– Battery powered and charge indicator– Constant current,voltage variable output– Adjustable and monitored current output– Monophasic square wave pulse (0.2-0.3 msec)– At least 50mA of output current– Audible or LED indicators of output

Monitoring Neuromuscular Function

TOF (Train of Four)

Why are mobile

technologiesimportant to

students?

THANK-YOU

Who is the Critical Patient?Who is the Critical Patient?

• TraumaTrauma

• Post-operativePost-operative

• Cancer Cancer

• SepticSeptic

• PancreatitisPancreatitis

• PyometraPyometra

• GDVGDV

• SeizureSeizure

• Severe GastroenteritisSevere Gastroenteritis

• Heart failureHeart failure

• HemorrhageHemorrhage

• Immune-mediated Immune-mediated disease.disease.

• Renal failureRenal failure

• Liver failureLiver failure

• And the list goes And the list goes on…….on…….

The EndThe End

8 Axes of Clinical Anesthesia 8 Axes of Clinical Anesthesia Monitoring Monitoring

(A Conceptual Model)(A Conceptual Model) Axis I - Airway /RespiratoryAxis I - Airway /Respiratory Axis II - Circulatory / VolumeAxis II - Circulatory / Volume Axis III - Depth of AnesthesiaAxis III - Depth of Anesthesia Axis IV - NeurologicalAxis IV - Neurological Axis V - Muscle RelaxationAxis V - Muscle Relaxation Axis VI - TemperatureAxis VI - Temperature Axis VII - Electrolytes / MetabolicAxis VII - Electrolytes / Metabolic Axis VIII - CoagulationAxis VIII - Coagulation

Cardiac Monitoring Cardiac Monitoring MethodsMethods

Symptoms and signs: Symptoms and signs: eg, angina, diaphoresis, eg, angina, diaphoresis,

mental statemental state Finger on the pulse:Finger on the pulse: rate, rhythm, pulse “volume” rate, rhythm, pulse “volume”

Auscultation: Auscultation: rate, rhythm, murmurs, extra soundsrate, rhythm, murmurs, extra sounds

ElectrocardiogramElectrocardiogram: rate, rhythm, ischemia: rate, rhythm, ischemia Pulse oximeter waveform: Pulse oximeter waveform: rate, rhythmrate, rhythm Blood pressure: Blood pressure: cuff, oscillotonometry, art. linecuff, oscillotonometry, art. line

Volume Status: Volume Status: low-tech, high-techlow-tech, high-tech