Physiologic Monitoring

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Physiologic Monitoring

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

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