General surgery and anesthesiology 4th study year FVM · –Uveitis, glaucoma. Patient monitoring, anesthetic complications Pharyngeal reflex •Is missing between II. a III. stage

Patient monitoring, anesthetic complications

Patient monitoring

General surgery and anesthesiology

4th study year FVM


History

• 1625 – Santorio di Venezia– Temperature – spirituous thermometer– Pols frequency – using pendulum

• 1733 – Stephen Hales– Bloodily in horse

• 1896 – sphygmomanometer– Using cuff

2


History

• 1903 – Willem Einthoven– Galvanometer – ECG– 1924 Nobel price

• 1935 – K. Matthes, G. Millikan, E. Wood– Pulse oximetry

• XX.th centuriy – John Scott Haldane– Capnography (1978)

3


Monitoring

• Non-electronic = clinical

– Pulse rate, breathing, mucous membrane color, …

– Reflexes, pain, eye globe rotation, …

• Electronic = equipment

– ECG, oximetry, capnometry, temperature, muscle relaxation, …


• Monitoring and assessment of selected parameters

• Patient and medical equipment

• Continually or repeatedly

• Marginal limits – alarms

• Monitoring is NOT a treatment !!!

• Help for diagnostics, therapy and prognosis

• Necessary for invasive and diagnostic procedures

Monitoring


Monitoring

Negative consequences

• Risk and discomfort for patient

• Price

• Risk of non-precise measurements

• Wrong interpretation

• More intense concentration of staff on the monitor than on the patient


Non-electronic monitoring

• Vision– Mucosa (color), movement (thorax, limbs), eye

(position, pupil), surgical site (bleeding), …• Touch

– Pols, CRT, muscle tone, temperature, …• Hearing

– Heart, lung, inhalation machine, electronic dev., …• Smell

– Leak of inhalation system


Non-electronic monitoring

• Circulation

• Respiration

• Eyelids, eye globe, pupil

• Pharyngeal reflex

• Muscle tone

• Others

– Anus, flexor reflex, …


Breathing

I. II.III.

IV.a b c

Tidal volume↑↑↑

apneaapnea ↓ ↓↓ ↓↓↓

Depth of respiration

deepsuper-ficial

deepsuper-ficial

apnea

Type Mixed diaphragmatic Apnea

Regularity irregular regular


Abnormalities

• Drugs

– Opioids

– General anesthetics

– Muscle relaxants

• Respiration abnormalities

– Chest wall trauma

– Lung disease

Breathing


I. II.III.

IV.a b c

Pulsestrong, accele-rated

? arthyt-mias ?

irregularnon

palpable

CRT < 1 s > 1 s

Mucous color pink cyanosis

Circulation


Abnormalities• Drugs

– Anticholinergics – atropine

– Alpha-2 agonists – dex/medetomidine, opioids

– Dissociatives

• Cardiovascular abnormalities

– Heart disease

– Hypovolemia, shock

Circulation


Esophageal stethoscope

• Blind tube with holes• Closest contact with the

heart• Minimum of disruptive

factors• Correlation of sounds and

SAP

(Sakamoto a kol. 1965)


Eye signs

I. II.III.

IV.a b c

Globe Nystagmus

Pupilar reflex +++ ++ + 0 0 0

Tear production +++ ++ 0 0 0 0

Palpebral reflex +++ ++ 0 0 0 0

Corneal reflex +++ +++ + 0 0 0


Analgezia Excitation Superficial anesthesia

Deep anesthesia

Paralysis

Eye signs


Eye signs

Abnormalities

• Drugs

– Anticholinergics – atropine

– Dissociatives

– Muscle relaxants

• Eye abnormalities

– Uveitis, glaucoma


Pharyngeal reflex

• Is missing between II. a III. stage of anesthesia

• Patient can be intubated

Abnormalities

• Dissociatives

• Cats

– Laryngospasm

– Deep anesthesia


Muscle tone

Eyelids, accomodation

strabismus

Masseters

Larynx, pharynx

Limbsfore – hind

distal – proximal

Abdominal

muscles

Intercostal muscles

Diaphragma


Others

• Anal sphincter

– Deep anesthesia

• Relaxation (muscle relaxation, opioids)

• Masseters

• Flexor reflex

• Ear moving – CATS


Pain

• Pupil size

• Saliva production

• Vocalization

• Palpation response

• Mental status

• Spontaneous behavior

• (Trias, BP)


• Clinical monitoring = non-electronic+ Cheap‒ Sone parameters imponderable‒ Non-precise, experience necessary, values?, …

• Electronic monitoring+ Precise (relatively), values, trends, …‒ Expensive‒ „Electronic error“, …

Comparison


• Cardiovascular

• Respiratory

• Temperature

• Muscle relaxation

• Others

– Urine production

– Acid-base profile, …

– EEG, …

Electronic monitoring


Monitoring in human medicine

• Electrocardiography• Pulse oximetry• Arterial blood pressure• Capnography• Spirometry• Temperature• Anesthetic agents,

gases


Cardiovascular system

• Central part – heart

• Peripheral part – blood vessels

1. Delivery of oxygen, nutrition, hormones, …

2. Removal of metabolites

3. Maintenance of temperature


Cardiovascular function

• Electrocardiography

• Pulse oximetry

• Blood pressures

• (Capnometry)


Electrocardiography

• Heart frequency

• Heart rhythm

• 3 (5) leads (RA, LA, LL)

• Thorax

• Limbs

• Esophagus

• ST elevation analysis?

• Main II. lead

• (R wave preference)


Electrocardiography



QRS complexes?

Synchronic pols

and QRS complexes?

ROSC HR > 200 /min

VT

ELECTROSHOCKPEA

ECG – line?

AsystoliaVF

ELECTROSHOCK


Electrocardiography

Limitation

• Slow connection, leads "obstruct"

• Interference – cauterization

• Without correlation between ECG and C.O.

• PEA, VT – electric activity without hemodynamic


• SpO2

– Hemoglobin saturation by oxygen

• Respiration

• Lung function

• Peripheral perfusion

– Sensor

• Tongue, ear, rectal, digital

SpO2 = 98 % ~ PaO2 = 100 mmHg

Pulse oximetry


Pulse oximetry

99 % O2 bound to Hb

32

Systola

Pulzující krevNení pulzace

Venózní krev

Diastola

Čas

Arteriální krev

Arterioly s různým průměrem =pletysmografická křivka

Tkáň

Světloproniklétkání

Emitované

světlo

Intenzitasvětla proniklého tkání

Systola

Pulzující krevNení pulzace

Venózní krev

Diastola

Čas

Arteriální krev

Arterioly s různým průměrem =pletysmografická křivka

Tkáň

Světloproniklétkání

Emitované

světlo

Intenzitasvětla proniklého tkání

néinfračerve

červené

2maxmin/ln

maxmin/lnfSpO

Red 660 nm Infrared 940 nm


Pulse oximetry

33

Sensor• Transmission• Reflexive


Pulsní oxymetrie

• Advantages

– Simple, quick continuous measurement

• Disadvantages

– Interference – movement (tremor), arrhythmias, electrocautery, laser, fluorescent lamp, pigmentation, "dyshemoglobins", …

– Weak peripheral perfusion

– Hypothermia, hypotension, hypovolemia, low C.O., …

– Decrease of 400 mmHg (PaO2 500 → 100 mmHg)

= decrease of 1 % SpO2 (99 → 98 %)


Hypoxia

(SpO2 < 90 %, PaO2 < 60 mmHg)

Interference

• Ischemia

• Pigmentation

• Electrocauterization

Pulse oximetry


ABP = C.O. x SVR C.O. = HR x SV

•Arterial pressure – SAP, DAP, MAP

• Measured indirectly

• Oscilometric (cuff)

• Ultrasound – Doppler effect

• Measured directly (MAP 60–120 mmHg)

•Venous pressure – CVP, PVP

• Measured directly (CVP 0–5 cmH2O)

Blood pressure


Arterial pressure

• Oscillometric


Oscillometry

• Cuff size– 40 % of limb circumference– Smaller – overvaluation– Larger – undervaluation

• Cuff position– Under heart – overvaluation– Above heart - undervaluation

38


• By ultrasound

– Doppler effect

Arterial pressure


• Pressure transducer

• Ameroid manometer

Arterial pressure

1 systole2 dicrotic notch3 diastolePressure transducer with flushing

Artery – transducer connecting tubeArterial catheter

Monitor

F1/1 + heparin


Arterial pressure

• Complication– Oscilo-, Doppler

• Reduction of perfusion up to 75 %

• Ischemia, edema, hematoma

– Bloodily

• Hematoma, thrombosis, Ischemia, infection, pseudo-aneurysma


Oscilo- / Doppler / bloodily?42

Oscilo- Doppler Bloodily

Accuracy Relative Good High

Drug influence Important Less Non-important

Arrhythmias High High Low

Continuity No No Yes

Advantages Simplicity AccuracyAccuracy, blood

samples

Disadvantages Accuracy ComplicatedInvasively,

complicity

Technique,

priceLow Low High


Central venous pressure

• Into v. cava cranialis or RA

• By catheter through jugular vein before RA

– With water column

– With electronic transducer

• Information of fluid balance

• Information of right heart function


Venous pressure

Plu

nket

tSJ

2000

: E

mer

genc

ypr

oced

ures


Central venous pressure

(CVP = 0–7 cmH2O)

Decreased CVP

• Hypovolemia

- Fluids

Increased CVP

• Heart, kidney insufficiency

- Causal


Other blood pressures

• Swan-Ganz catheter


Respiratory system

• Central part – lungs

• Peripheral part – airways

1. Oxygen delivery and other drugs

2. CO2 removal and other drugs

3. Maintenance of body temperature

4. Close "cooperation" with cardiovascular system


Functional status of the lungs

• PAO2 PaO2

PaO2 / FiO2

Pathology < 200 300 > 500 NormalMiddle Mild

A-a gradient = PAO2 – PaO2

Normal < 15 mmHg Abnormal > 25 mmHg


A-a gradient

Without pathology Lung pathology

FiO2 21 % (0,21) 21 % (0,21)

PaO2 74 mmHg 74 mmHg

PaCO2 58 mmHg 31 mmHg

PAO2 = FiO2 (PB – PH2O) – (PaCO2 / RQ)

PAO2 76,6 mmHg 110,4 mmHg

A-a gradient

= PAO2 – PaO2

2,6 mmHg 36,4 mmHg

A-a gradient < 15 mmHg (normal) > 25 mmHg (abnormal)

PB – barometric pressure (760 mmHg), PH2O – partial pressure of H2O (50 mmHg), RQ – respiration kvocient (0,8)


• Pulse oximetry

• Capnometry

• Spirometry

• AA

• Blood gases

• Tomography

Respiration


Monitoring in human medicine

• Electrocardiography• Pulse oximetry• Blood pressure• Capnography• Spirometry• Temperature• AA, resp. gases


Respiratory frequency monitoring

• Using thermistor• By electro-impedance


Capnometry/-graphy

• PaCO2 – gold standard respiratory evaluation• Healthy lungs – PaCO2 ~ EtCO2

• Lung ventilation• Lung perfusion (C.O.)• Tissue metabolism• End-tidal CO2 (EtCO2)

(35–40 mmHg)Non-invasive monitoring


• Lung ventilation

• Lung perfusion

• End-tidal CO2 (EtCO2)

Capnometry

Side stream

Main stream


Main-/Sidestream

Mainstream Sidestream

Accuracy Good High

Response Fast Slow

Dead space Enlargement Uninfluenced

Gas sample 0 50–150 ml min-1

Water trap No Yes

Connection ETR ETR, mask


Capnography

• Capnometry/capnography

A-B base line D End-tidal CO2 (EtCO2)

B-C expirium D-E inspirium

C-D expiration plato



Capnometry/-graphy

• Gold standard of esophageal intubation

• Along with constant ventilation (IPPV) EtCO2

represents C.O.

• Capnogram not influenced by chest compression during CPR

• Sidestream – with inhalation mask too

• Monitoring of patient and breathing system


Spirometry

• Frequency, volume, time– fR, VT, MV– Ti : Te, respiration pause

• Pressure in airways– PIP, PEEP

• Compliance


• Pitot tube +

electronic module

• Manometer +

ventilometer

Spirometry


Spirometry


Gas monitoring– AA

• Oxygen – FiO2, EtO2 – low-flow, minimal-flow• Nitrous oxide – FiN2O, EtN2O• Isofluran, Sevofluran, Desfluran, Enfluran, … – Fi, Et• Interference – methane – large animals


Electro-impedance tomography


Temperature

• Core temperature

– Esophageal

• Rectal temperature

• Peripheral temperature

– Skin – interdigital

– About 2-4 °C lower


Neurostimulators

– N. ulnaris

– N. peroneus

– N. facialis

• 60–80 mA

• 0,2 ms

Muscle relaxation


1,0 0,8 0,6 0,4 0,4

A B C D E

Muscle relaxation

• Single burst stimulation

• Train-of-Four

– TOFR (T1:T4)

– TOFR ˃ 0,9

spontaneous breathing

• Tetanic stimulation

• Double-Burst-Stimulation


"Train-of-four"


(3.1–6.7 mmol/l)

• Young animals

• Diabetes mellitus

• Sepsis

• Insulinoma

• Portosystemic shunt

Glycaemia


Urine production

(1–2 ml/kg/h)

• Catheter + sampling bag

• Kidney function

– Perfusion

– Circulatory volume

– (CVP)


Oliguria

• Insufficient replacement + loss of fluids• Nephropathy• NSAIA• Morphine

- Fluids- NE, Furosemide, Glucose, Manitol- Dopamin, Dobutamin


Acid-base status, blood gases

• pH (7,35–7,45)

• PaO2 (80–100 mmHg)

• PaCO2 (35–45 mmHg)

• HCO3- (22–25 mmol/l)

• (Kooxymetry)





Parameters (DOG)

• RR 10–20 /min

• HR 30–120 /min

• T 37.5–39.0 °C

• SpO2 95–100 %

• EtCO2 4.5–5.5 kPa (30–45 mmHg)

• BP SAP 120–140 mmHg

DAP 80–100 mmHg

MAP 100–110 mmHg


Anesthetic complications

General surgery and anesthesiology

4th study year FVM


Anesthetic complications

• Respiratory

• Cardiovascular

• Temperature

• Metabolic

• Neuromuscular

• Gastrointestinal


• Abnormalities of gas exchange

– Hypoxia, hypercapnia, hypocapnia

• Obstructive disease of airways

• Hyperventilation

• Aspiration

• Lung edema

• Complication of intubation

Respiratory complication


Abnormalities of gas exchange

HypoxiaBrain, heart, spinal cord, kidneys, liver

Sympathic activation

Tachy/bradycardia

Hyper/hypotension

↑ – ↓ C.O.

↑ – ↓ contractility

↑ – ↓ SVR

Hypercapniasee hypoxia

↑ CO2 – ↓ O2 in alveolus

Displ. of Hb dissoc. curve


Hypoxia

(SpO2 < 90%, PaO2 < 70 mmHg)

V/Q mismatch, R/L shunt

• Apnea, hypoventilation

• Lung restrictive disease (internal, external)

• Low FiO2

• Obstruction of airways

• Anemia, hypotension, CPA


Hypoxia

Management- Oxygen

- Oxygen collar

- Oxygen box

- Nasal catheter

- Artificial lung ventilation

- Bronchodilators


Hypercapnia

(EtCO2 ˃ 55 mmHg)

• Hypoventilation

– Neuromuscular abnormalities (anesthetic depth)

– Restrictive diseases of thorax and abdomen

– Air, fluid, CO2 in pleural cavity

– Terminal phase of lung parenchyma abnormalities, rebreathing from death space

• Hyperthermia, increase of CO2 production

• Bicarbonate therapy


Hypocapnia

(EtCO2 < 30 mmHg)

• Hyperventilation

• Obstruction or leak of breathing system

• Hypothermia

• Decrease of metabolic ratio

• Hypotension

– Lung (emboli, …)

– Systemic


Cardiogenic oscillation

Sudden decrease to zero

Sudden decrease


System leakage

Rebreathing

Rebreathing – Bain system


Airways intake

Esophageal intubation

Endobronchial intubation


Airways obstruction

Upper airways

• BOAS, obstruction, laryngeal paralysis

- O2, clear airways, steroids, diuretics, sedation

Lower airways

• Bronchospasm, asthma, anaphylaxis

- O2, bronchodilators, steroids, antihistaminic


Spirometry

A. Normal B. Lung emphysema C. Extra-thoracic obstruction F. Intra-thoracic obstruction

C. Unilateral obstruction D. Upper airways obstruction G. Restrictive lung disease H. Muscle weakness


Hyperventilation

Increase of MV

• Insufficient anesthetic depth, analgesia

• Hypoxemia

• Hypercapnia

• Hyperthermia

• Metabolic abnormalities (MAC, …)

- Causal


Aspiration

Digestion, blood, saliva, …

• Decrease of tone of lower esophageal sphincter (anesthetics)

• Slower passage of gastric content

• Increased intraabdominal pressure (distension, laparoscopy, …)

- Food restriction, prokinetics, body position, hygiene

- Extubation after restoration of swallowing reflex


Lung edema

• Patients with heart, kidney abnormalities

• Excessive fluid therapy

- Oxygenation

- Sedation

- Furosemide


Complication of intubation

Irritation of larynx and traches

• Excessive pressure in cuff

• Dentistry

- Cuff-pressure max. 20 cm H2O

Cuff herniation

• Risk of airways obstruction

- Check-up before use

ETR obstruction

• Intubation error, secrets, (foreign body)

- Checking ET, Murphyho eye


• Bradyarrhythmia (bradycardia)

• Tachyarrhythmia (tachycardia)

• Heart arrhythmias

• Systemic hypotension

• Systemic hypertension

• Cardiopulmonary arrest

Cardiovascular complication


• Sinus bradycardia (< 60 beats/min)

– Anesthetics, vagal tone, hypothermia, hypoglycemia, hypertension, hyperkalemia, …

• AV block

– Anesthetics, vagal tone, … – Atropine, Ketamine, Atipamezol

• Sick sinus syndrom

– Valvular abnorm. … – Atropine

• PEA, asystolia

– CPR

Bradyarrhythmia


Tachyarrhythmia

• Sinus tachycardia (> 180 beats/min)

– Anesthetics, analgesics, hypotension, hypovolemia, hypercapnia, hypokalemia, hypercalcemia, hypoxia, hypomagnesemia, …

• Atrial fibrilation

– Vagal tone, … – Lidokain, (Esmolol)

• Ventricular fibrilation

– CPR

• Ventricular premature complexes

– Lidocaine, Amiodarone


Arrhythmias

• Ventricular arrhythmias

– Lidocaine 1–2 mg/kg + 0,025–0,1 mg/kg/min

– Amiodaron 2–5 mg/kg (incl. supraventricular)

• Supraventricular tachycardia

– Esmolol 0,05–0,5 mg/kg + 0,0025–0,2 mg/kg/min

– (Diltiazem 0,1–0,25 m/kg + 0,1–0,3 mg/kg/h)


Hypotension

(SAP < 90 mmHg, MAP < 60 mmHg)

Decreased venous return

• Vasodilation, hypovolemia, bradycardia, IPPV, effusion, pneumothorax

• Isoflurane, Propofol, Acepromazine

- Fluids, Dopamine, NE, E, Vasopresine, Fenylefrine

Ventricular dysfunction

- Dopamine, Dobutamine, Norepinephrine, Epinephrine


Hypertension

• Pain, insufficient anesthetic depth

• Hypoxia, hypercapnia

• Systemic hypertension

– Hyperadrenocorticism, hyperthyreosis, CRF, Diabetes mellitus, pheochromocytoma, hyperaldosteronismus

• Drugs (alpha-2 agonists, vasopressors, …)

• Metabolic acidosis

- Causal

- ACE-inhibitors, beta-blockers, Isoflurane, Propofol


Cardiopulmonary arrest

• Clinical signs

– Apnea

– Non-palpable pulse and heart beat

– Absence of heart sounds

– Pale or cyanotic mucosa

– Mydriasis

– Muscle weakness (anal sphincter)

– Absence of bleeding


CPA

• Diagnostics

– ABC – Airways, Breathing, Circulation

– Max. within 15 seconds!!!

• CPA – 100% YES – start BLS

• CPA – ??? – start BLS

• CPA – 100% NO – diagnostic and stabilization

• Management of CPA

– CAB – Circulation, Airways, Breathing



Small dogs, cats

Large dogs

Flet

cher

DJ

20

14

: C

PR

: Ba

sic

& A

dva

nce

d L

ife

Sup

po

rt

Chest compression


Dogs withflat thorax

Dogs withtriangular thorax

Chest compression

Flet

cher

DJ

20

14

: C

PR

: Ba

sic

& A

dva

nce

d L

ife

Sup

po

rt


QRS complexes?

Synchronic polsand QRS complexes?

ROSC HR > 200 /min

VTELECTROSHOCK

PEA

ECG – line?

AsystoliaVF

ELECTROSHOCK


Pulseless VT Fibrillation



Hypothermia

(37–38 °C, 98.6–100.4 F)

• Laparotomy, thoracotomy

• Inhalation anesthesia, CNS depression, muscle relaxation

• Acepromazine

- Warming

- 0,5 °C/h


Hyperthermia

• BOAS, excessive coat

• Hyperadrenocorticism

- Oxygenation

- Cooling (alcohol on skin)

- Lavage of urinary bladder

- Acepromazine, Propofol

- IPPV


Hypoglycemia

(3.1–6.7 mmol/l)

• Young animals

• Diabetes mellitus

• Sepsis

• Insulinoma

- Glucose (2.5%)


Oliguria, anuria

(1–2 ml/kg/h)

• Nephropathy• Insufficient fluid substitution + fluid loss• NSAIDs• Morphine

- Fluid therapy- Furosemide, Glucose, Manitol- Dopamine, Dobutamine


Myopathy, neuropathy

• Wrong positioning (HORSE)• Long anesthesia• Hypotension

- Patient positioning- Pad out of exposing body parts- Normotension, normovolemia


Excitation, vocalization

• Pain

• Opiods, ketamine, benzodiazepins, propofol

• Hypoglycemia, hypothermia, hypomagnezemia

- Causal (glucose, temperation, MgSO4, …)

- Analgesics

- Diazepam, Barbiturates, Medetomidine

- Antagonisation


Anaphylactiod reaction

• Drugs, disinfection agents, …

• Dyspnoe, edemas, tachypnoe, hypoxemia, tachycardia, arrhythmia, hypotension, erythema

- Oxygenation

- Fluid therapy (Crystaloids, colloids)

- Epinephrine, difenhydramine

- Bronchodilatans


• Vomiting, regurgitation, defecation

– Extubation after swallowing recovery

– Enema

• Urination

– Catheterization

Gastrointestinal and neuromuscular abnormalities


Pain

• Vocalization, restless, changes of body position, …

• impaired

– Homeostasis

– Immune response

– Wound healing

– Convalescence


Post-resuscitation care

• Normoxia, normocapnia

• Mild hypertension

• Hydration

• Normothermia

• Repeated clinical examination

• Neurologic status

• Urine production


• Hematology, biochemistry, acid-base

• Lung functions, oxygen saturation

• Analgesics?

• Antibiotics?

• Prevention of decubital lesions

Post-resuscitation care

Documents

General surgery and anesthesiology 4th study year FVM · –Uveitis, glaucoma. Patient monitoring, anesthetic complications Pharyngeal reflex •Is missing between II. a III. stage