Physiologic Monitoring

  • 1,181 views
Uploaded on

 

More in: Business , Technology
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
1,181
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
36
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. PHYSIOLOGIC MONITORING CELSO M. FIDEL, MD, FPCS, FPSGS Diplomate Philippine Board of Surgery
  • 2.  
  • 3. Parameters Monitored
    • Hemodynamic Monitoring
    • RESPIRATORY Monitoring
    • Renal Monitoring
    • Neurologic monitoring
    • Metabolic monitoring
    • temperature monitoring
  • 4. Hemodynamic Monitoring
    • 1. Provides information as to the C-P status of the patient
    • 2. Traditional clinical assessment are usually unreliable
    • 3. Major changes in the cardiovascular status may not be clinically obvious
    • 4. Invasive techniques must be utilized
  • 5. Hemodynamic Monitoring
    • A. Arterial Catheterization
    • 1. Indications
    • a. Need for continuous blood pressure monitoring.
    • b. Need for frequent arterial blood sampling.
  • 6. Hemodynamic Monitoring
    • Conditions that need continuous and accurate BP monitoring:
    • i. Shock states
    • ii. Hypertensive crisis
    • iii. Surgery in high risk patients
    • iv. Use of potent vasoactive or inotropic drugs
    • v. Controlled hypotensive anesthesia
    • vi. Situations that may lead to rapid changes in cardiac function
    Arterial Catheterization
  • 7. Hemodynamic Monitoring
    • 2. contraindications
    • No ABSOLUTE contraindication to arterial catheterization
    • RELATIVE contraindications are:
    • a. Bleeding problems (hemophilia)
    • b. Anticoagulant therapy
    • c. Presence of a vascular prosthesis
    • d. Local infection
    Arterial Catheterization
  • 8. Hemodynamic Monitoring
    • 3. Sites of catheterization
    • a . R adial artery
    • b. Axillary artery
    • c. Femoral artery
    • d. Dorsalis pedis artery
    • e. Superficial femoral artery
    • f. Brachial artery
    Arterial Catheterization
  • 9. Hemodynamic Monitoring
    • 3. Sites of Catheterization
    • a. radial artery
    • - dual blood supply
    • - most commonly used site
    • - simple canulation
    • - low complication rate
    • - modified “Allen’s” test – assess ulnar artery
    • - Doppler technique, plethysmography, pulse oximetry
  • 10. Hemodynamic Monitoring
    • 3. Sites of Catheterization
    • b. axillary artery
    • - for long term monitoring
    • - large size
    • - close proximity to the aorta
    • - deep location
    • - technical difficulty in insertion
    • - located near neurovascular structures
  • 11. Hemodynamic Monitoring
    • 3. Sites of Catheterization
    • c. femoral artery
    • - large size and superficial location
    • - prone to atherosclerosis
    • - difficult to keep clean
  • 12. Hemodynamic Monitoring
    • 3. Sites of Catheterization
    • d. dorsalis pedis
    • e. superficial temporal artery
    • - surgical exposure is required
    • - neurologic complications observed
  • 13. Hemodynamic Monitoring
    • 3. Sites of Catheterization
    • f. brachial artery
    • - for short term use only
    • - median nerve contracture (Volkman’s contracture)
  • 14. Hemodynamic Monitoring
    • Arterial Catheterization
    • 4. Complications of arterial catheterization
    • a. failure to cannulate
    • b. hematoma
    • c. disconnection from monitoring system
  • 15. Hemodynamic Monitoring
    • Arterial Catheterization
    • 4. Complications of arterial catheterization
    • d. infection
    • - catheters in place for more than 4 days
    • - surgical insertion
    • - local inflammation
    • e. retrograde cerebral embolization
    • f. A-V fistula / pseudoaneurysm
    • g. severe pain, distal necrosis
  • 16. Hemodynamic Monitoring
    • B. Central Venous Catheterization
    • 1. Indications
    • a. access for fluid therapy
    • b. access for drug infusion
    • c. parenteral nutrition
    • d. CVP monitoring
  • 17. Hemodynamic Monitoring
    • B. Central Venous Catheterization
    • 1. Indications
    • e. other indications
    • - aspirate air embolism
    • - placement of cardiac pacemaker / vena cava filters
    • - hemodialysis access
  • 18.  
  • 19. Hemodynamic Monitoring
    • B. Central Venous Catheterization
    • 1 . Useful in hypotensive patients
    • 2. Tracings for arrythmias
    • 3. Gives information about the relationship
    • between intravascular volume and right
    • ventricular function
    • 4. Use of a water manometer for pressure
    • measurements
    • 5. Normal CVP measurement 4-7 mmH2O
  • 20.
    • Central Venous Pressure Monitoring
    •  In seriously ill patients the vital problem is
    • determination of the proper amount of fluids
    • and blood requirements necessary to
    • MAINTAIN an optimal blood volume in the:
    •  Preoperative
    •  Operative
    •  Postoperative
    Hemodynamic Monitoring
  • 21. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    •  CVP Monitoring is a reliable procedure
    • to evaluate properly and promptly
    • optimal fluid and blood requirement
    • in these patients .
    •  The procedure removes much of the
    • guess work in rapid restoration and
    • maintenance of adequate circulation
    • w/o fear of overloading the heart
  • 22. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    • 2. Sites of catheterization
    • a. subclavian vein
    • - easiest to cannulate
    • - pneumothorax most common complication
    • - difficult to control bleeding
  • 23. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    • 2. Sites of catheterization
    • b. internal jugular vein
    • - lower risk of pneumothorax
    • - arterial puncture most common complication
    • c. external jugular vein
    • d. basilic vein
  • 24. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring (
    • .
    •  CVP measured anywhere in the SVC or IVC or
    • their immediate tributaries>>>Innominate,
    • and the Common Iliac Veins
    •  It is determined by a complex interaction of:
    •  Blood Volume
    •  Cardiac Pump Action
    •  Vascular Tone
    •  Serves as index of circulating blood volume
    • relative to the Cardiac Pump Action
  • 25. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring (
    •  CVP or the pressure in the Right Atrium &
    • adjacent Caval system will reflect ability of
    • the Cardiac Pump Action to handle the
    • returning blood volume at that particular time.
    •  Indications:
    •  When Massive blood replacement is
    • instituted rapidly in rapid exsanguinating
    • type of bleeding.
  • 26. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring (
    •  Indications:
    •  In Acute blood volume deficit in cases
    • operated for strangulating type of Intestinal
    • Obstruction where rapid fluid replacement is
    • indicated
    •  In obscure cases of Shock immediately post-
    • op whether hypovolemic due to internal
    • bleeding or nonhypovolemic from Myocardial
    • Infarction.
  • 27. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring (
    •  Indications:
    •  In elderly patients with limited cardiac
    • reserve undergoing difficult, time
    • consuming operations.
    •  In surgical patients with anuria due to
    • possible renal shutdown.
  • 28. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    • Basic Facts about CVP .
    •  Normal CVP is about 4 to 7 cm
    •  Low CVP 0-3 circulating blood vol. is
    • below the normal blood volume the
    • heart can handle.
    •  High CVP 8-20 (more than the heart can
    • handle)
  • 29. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    •  Technique
    •  Cannulation of the Superior Vena Cava
    • through Basilic or Cephalic Veins.
    •  A polyethelene tube size French 8 and 42
    • inches long is inserted at the Basilic Vein just
    • above the elbow and pushed up to 20 inches.
  • 30. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    •  Technique
    •  Connect an Intravenous administration set
    • to the venous catheter through which IV fluid,
    • may be administered.
    •  A Manometer is connected to IV set w/ a
    • three way stopcock. Zero point should be at
    • level of the Atrium or approximately at
    • Mid-axillary line
  • 31. Hemodynamic Monitoring
    • Central Venous Pressure Monitoring
    • Complications
    • 1. catheter malposition
    • 2. dysrythmmias
    • 3. embolization
    • 4. vascular injury
    • 5. cardiac, pleural, mediastinal, neurologic
    • injury
  • 32. Respiratory Monitoring
    • Monitoring ventilation and gas exchange
    • * Indications
    • 1. Decision making for the need of mechanical ventilation.
    • 2. Assessment of response to therapy.
    • 3. Optimize ventilatory management.
    • 4. Decision to wean from ventilator.
  • 33. Respiratory Monitoring
    • Monitoring ventilation and gas exchange
    • A. Ventilation monitoring
    • 1. Tidal volume – volume of air moved in or out
    • of the lung in a single breath
    • 2. Vital capacity – maximal volume at expiration
    • after a maximal inspiration
    • 3. Minute volume – total volume of air leaving
    • the lung each minute
    • 4. Phsiologic dead space – the portion of tidal volume that does not participate in in gas exchange
    • a. anatomic dead space
    • b. phsiologic dead space
  • 34. Respiratory Monitoring
    • Monitoring ventilation and gas exchange
    • A. Ventilation monitoring
    • 4. Phsiologic dead space – the portion of tidal
    • volume that does not participate in in gas
    • exchange
    • a. anatomic dead space
    • b. phsiologic dead space
  • 35. Respiratory Monitoring
    • Monitoring ventilation and gas exchange
    • B. Gas Monitoring
    • - Reported as directly measured partial
    • pressures (PO2 and PCO2)
    • - Use of pulse oximeters for continuous
    • measurements
    • 1. Blood gas analysis – information about:
    • a. efficacy of gas exchange
    • b. adequacy of alveolar ventilation
    • c. acid – base status
  • 36. Respiratory Monitoring
    • Monitoring ventilation and gas exchange
    • B. Gas Monitoring
    • 2. Capnography
      • - graphic display of CO2 concentration in wave form
      • - available systems
      • a. infrared analysis
      • b. mass spectrometry
      • c. Raman scattering
      • d. disposable colorimetric devices
      • e. semi-quantitive measurement on the end- tidal CO2 concentration
  • 37. Respiratory Monitoring
      • B. Gas Monitoring
      • 3 . Pulse oximetry
      • reliable, real time estimation of the arterial Hgb saturation
      • - wide clinical acceptance
  • 38.  
  • 39. Respiratory Monitoring
    • Monitoring ventilation and gas exchange
    • B. Gas Monitoring
    • 4. Gastric Tonometry
    • - relatvely non-invasive monitoring of
    • adequacy of aerobic metabolism in
    • organs whose superficial mucosal
    • lining is extremely vulnerable to low flow changes and hypoxemia
  • 40. Renal Monitoring
    • The kidney is an excellent monitor of
    • adequacy of perfusion
    • Prevention of renal failure
    • Predict drug clearance and proper dose
    • adjustment
  • 41. Renal Monitoring
    • A. Urine Output
    • - Commonly monitored but may be misleading
    • - Normal urine output  0.5 ml/kg/hour
    • - Correlates with glomerular filtration rate (GFR)
    • - High output may not accurately reflect GFR
    • ex. Diabetes Insipidus
    • - May be affected by other factors
  • 42. Renal Monitoring
    • B. Glomerular Function Tests
    • 1. Blood Urea Nitrogen (BUN)
    • a. Affected by GFR and urea production
    • b. Increased in TPN, GI bleeding, trauma,
    • sepsis, steroid use
    • c. Lowered in starvation, liver disease
    • d. Not a reliable test
  • 43. Renal Monitoring
    • 2. Plasma Creatinine
    • a. More accurate than BUN
    • b. Directly proportional to creatinine
    • production
    • c. Inversely related to GFR
    • d. Not affected by protein or nitrogen
    • production or rate of fluid flow through
    • tubules
    • e. Related to muscle mass
  • 44. Renal Monitoring
    • 3. Creatinine Clearance
    • a. used if values of plasma creatinine are
    • affected by muscle disease
    • b. serial determination of urine is done and
    • is currently the most reliable method
    • of assessing GFR
  • 45. Renal Monitoring
    • C. Tubular Function Tests
    • 1. The most reliable test to distinguish pre- renal azotemia from tubular necrosis
    • 2. Requires simultaneous collected urine
    • and blood samples
  • 46. Neurologic Monitoring
    • Early recognition of cerebral
    • dysfunction
    • Facilitate prompt intervention
    • and treatment
  • 47. Neurologic Monitoring
    • A. Intracranial Pressure Monitoring
    • 1. Cerebral Perfusion Pressure - >70mmHg
    • 2. Glasgow Coma Scale
  • 48. Neurologic Monitoring
    • B. Electrophysiologic Monitoring
    • Reflects spontaneous and on-
    • going electrical activity in the
    • brain
  • 49. Neurologic Monitoring
    • C. Trans-cranial Ultrasound
    • Monitors cerebral blood flow
    • Detects vasospasm
  • 50. Neurologic Monitoring
    • D. Jugular Venous Oximetry
    • Measures relationship of blood flow
    • to O2 consumption
  • 51. Metabolic Monitoring
    • A. Caloric Demands
    • B. Respiratory Quotient of Food
  • 52. Temperature Monitoring
    • A. Rectal
    • B. Middle Ear
    • C. Esophageal
  • 53. THANK YOU!!!