Monitoring of critically ill presentation by kully ishfaq. Soura Srinagar kashmir.

1. Topic : Monitoring of Critically Ill
Presented by:
Ishfaq
Ahmad

2. INTRODUCTION
• "Repeated or continuous observations or measurements of
the patient, his or her physiological function, and the
function of life support equipment, for the purpose of
guiding management decisions, including when to make
therapeutic interventions, and assessment of those
interventions".
• A patient monitor may not only alert caregivers to
potentially life-threatening events; many provide
physiologic input data used to control directly connected
life-support devices.

3. CATEGORIES OF PATIENTS WHO NEED
MONITORING
• There are at least four categories of patients who need
physiologic monitoring:
• Patients with unstable physiologic regulatory systems; for
example, a patient whose
• Patients with a suspected life-threatening condition; for
example, a patient who has findings indicating an acute
myocardial infarction (heart attack).
• Patients at high risk of developing a life-threatening condition;
for example, patients immediately post open-heart surgery, or a
premature infant whose heart and lungs are not fully
developed.
• Patients in a critical physiological state; for example, patients
with multiple trauma or septic shock.

4. SYSTEMS TO BE MONITORED
• CARDIOVASCULAR MONITORING
• RESPIRATORY MONITORING
• CENTAL NERVOUS SYSTEM MONITORING
• RENAL SYSTEM MONITORING
• HEPATIC SYSTEM MONITORING
• HEMATOLOGICAL MONITORING

5. CARDIOVASCULAR MONITORING
• Cardiovascular monitoring include –
– Continuous cardiac monitoring
– 12-Lead ECG

6. Continuous cardiac monitoring
• Continuous cardiac monitoring allows for rapid assessment
and constant evaluation.
• It is now common practice for five leads.
• The monitoring lead of choice is determined by the patient's
clinical situation.

7. 12-Lead ECG
• ECG Interpretation
• Heart rate: Count the R waves on a 6 sec strip and multiply by
10 to calculate the rate.
• Rhythm (regularity): To assess regularity, The R-R interval
should not differ by more than 0.12 sec.
• Atrial activity: Observe for the presence or absence of P
waves.
• AV node activity: The duration of the P-R interval
• Ventricular activity: Measure the QRS interval And Q wave (if
present) = less than 0.04 sec.

8. • Heart Rate
– Heart rate is a nonspecific parameter. It is usually measured by auscultation of
the heart and palpation of an artery, automatically taken from an ECG or arterial
pulse pressure wave.
– Increase in heart rate (tachycardia) may be caused by hypovolemia (the
tachycardia is a compensatory mechanism), fever, excitement, exercise and pain.
– Decrease in heart rate (bradycardia) may be caused by high vagal tone, severe
electrolyte disturbances and atrioventricular conduction blocks.
• Heart Rhythm
– When irregularities in heart sounds are heard, the heart rate should be compared
to pulse rate and the difference in rates are called pulse deficits. Pulse deficits
are indicative of arrhythmias. Hypoxia, myocardial contusions and metabolic or
acid base imbalance may cause arrhythmias.
– Some examples of cardiac arrhythmias include- premature atrial contraction
(PAC), atrial fibrillation, premature ventricular contraction (PVC) and
ventricular tachycardia. All pulse abnormalities should be confirmed by a
electrocardiogram (ECG).

9. Some other parameters that are observed in
cardiovascular monitoring include-
• Mucous membrane color :
• The normal mucous membrane color is pink. In diseased state
the mucous membrane color may be yellow,pale,white,brick
red or blue.
• Capillary refill time(CRT) :
• It is an indication of peripheral perfusion. CRT is the rate at
which blood returns to the capillary bed after it has been
compressed digitally.
• Normal CRT is 1-2 seconds.
• Prolonged CRT is due to vasoconstriction.

10. HAEMODYNAMIC MONITORING
• The reasons for haemodynamic monitoring are -
– To establish a precise health-related diagnosis;
– To determine appropriate therapy; and
– To monitor the response to that therapy.
• Hemodynamic monitoring can be –
– Non-Invasive
– Invasive

11. Non-invasive Monitoring
Non-invasive monitoring does not require any device to be
inserted into the body and therefore does not breach the skin.
• Directly measured non-invasive variables include –
– Body Temperature,
– Heart Rate,
– Blood Pressure,
– Respiratory Rate,
– Urine Output,
– Trans cutaneous pulse oximetry
– Expired carbon monoxide monitors.

12. Invasive Monitoring
• Invasive monitoring requires the vascular system to be
cannulated and pressure or flow within the circulation
interpreted.
• Invasive haemodynamic monitoring technology includes:
– Systemic arterial pressure monitoring
– Central venous pressure
– Pulmonary artery pressure
– Cardiac output (Thermodilution).

13. Blood Pressure Monitoring
• Blood Pressure
– Normal B.P. (18 + age) = 100-120/60-80 mm Hg,
– Prehypertension = 120-139 /80- 90 mm Hg
– Hypertension = >140/90 mm Hg
– Hypotension = < 90/60 mm Hg
• Systemic arterial blood pressure can be measured by-
– Indirectly or non-invasive
– Directly or invasive

14. • Non-Invasive Blood Pressure Monitoring –
NIBP monitoring by the use of manual or electronic sphygmomanometer.
• Invasive Intra-Arterial Pressure Monitoring –
– Arterial pressure recording is indicated when precise and continuous
monitoring is required, such as in periods of instability of cardiac output and
blood pressure.
– Arterial cannula is placed in the artery. Most common site Radial Artery and
other sites are The Brachial, Femoral, Dorsalis Pedis and Axillary Arteries.
– Three main factors are monitored –
• Preload
• Afterload
• Contractility

15. Central venous pressure
Preload in the right ventricle is generally measured as CVP.
• Normal value of CVP is – 0 to +8 mm of Hg 'OR' 0 to +10 Cm H2O.
• A CVP less than 0 may be due to vasodilatation (increased volume
capacitance) or hypovolemia. A CVP in a normal range but in the face of
signs consistent with vasoconstriction may be due to hypovolemia.
• A CVP greater than 10 may be due to the heart's inability to function as a
pump or fluid over-load, vasoconstriction (decreased volume capacitance),
pericardial effusion and positive pressure ventilation.
• Locations used for central venous access:
– The commonest sites in critically ill patients are –
• Subclavian Vein Approaches
• Internal Jugular Vein Approaches

16. Pulmonary Artery Pressure (PAP)
• PAP monitoring is indicated for adults in severe hypovolaemic or
cardiogenic shock, where there may be diagnostic uncertainty, or where the
patient is unresponsive to initial therapy.
• The PAP is used to guide administration of fluid, inotropes and
vasopressors.
• PAP monitoring may also be utilised in other cases of haemodynamic
instability when diagnosis is unclear.
• It may be helpful when clinicians want to differentiate hypovolaemic from
cardiogenic shock or, in cases of pulmonary oedema, to differentiate
cardiogenic from non-cardiogenic origins.
• It has been used to guide haemodynamic support in a number of disease
states such as shock, and to assist in assessing the effects of fluid
management therapy.

17. Pulmonary Capillary Wedge Pressure
• Also known as Pulmonary artery occlusion pressure (PAOP).
• Measured by the pulmonary artery catheter balloon.
• Normally the PAOP varies between 8-12 mmHg.
• Patients with poor left ventricular function have a PAOP
exceeding 18mmHg.

18. Left Atrial Pressure Monitoring
• Left atrial pressure monitoring directly estimates left heart
preload.
• It requires an open thorax to enable direct cannulation of the
atrium
• It is used only in the postoperative cardiac surgical setting

19. RESPIRATORY MONITORING
• Respiratory insufficiency is one of the main reasons for
admission to a critical care unit, as either a potential or actual
problem, so comprehensive respiratory monitoring is
essential.
• The respiratory monitoring include –
– Pulse oximetry
– Arterial Blood Gases Analysis
– Ventilation monitoring

20. Pulse oximetry
• Normal SpO2 is greater than 97%.
• It is important that when SpO2 appears to be abnormal, the
arterial blood is sampled and gases are checked. Therefore,
arterial blood gases are also needed periodically to assess other
parameters.

21. Arterial Blood Gases Analysis
• Arterial blood gases (ABGs) are one of the most commonly
performed laboratory tests in ICUs and other critical care
areas.
• ABG measurements are essential for assessing
oxygenation/gas exchange and ventilation.
• ABGs are measured to determine the status of the acid–base
balance and oxygenation, and include measurement of the
PaO2, PaCO2, acidity (pH) and bicarbonate (HCO3
-).
• Continuous blood gas monitoring is possible if a fibreoptic
sensor or an oxygen electrode is inserted into the arterial
catheter system. The advantage of the arterial catheter is that it
facilitates ABG sampling without repeated arterial punctures.

22. Ventilation Monitoring
Measurements Description Normal Value
Temperature (T) Default setting is 37°C. No consensus on
analysis according to patient temperature.
Consistency of greater importance.
37°C
Haemoglobin (Hb) Samples need to be fully mixed so should
be constantly agitated until analysed.
Females 115–165
g/L
Males: 130–180 g/L
Acid–base status
(pH)
Overall acidity or alkalinity of blood. 7.36–7.44

23. Carbon dioxide
(PaCO2)
Partial pressure of arterial CO2. 4.5–6.0 kPa
35–45 mmHg
Oxygen (PaO2) Partial pressure of arterial oxygen. 11–13.5 kPa
80–100 mmHg
(varies with age)
Bicarbonate (HCO3
)
Standard bicarbonate is usually used to assess
metabolic function; this is calculated by
removing the respiratory component from the
HCO3 .
22–32 mmol/L
Base excess (BE) The number of molecules of acid or base that
are needed to return 1 litre of blood to the
normal pH (7.4): it measures acid–base
balance. As with HCO3 , standard BE is more
useful for accurate assessment of metabolic
components.
3 to +3 mmol/L
Saturation (SaO2) Haemoglobin saturation by oxygen in arterial
blood.
>94%

24. CENTAL NERVOUS SYSTEM
MONITORING
• CNS monitoring in critical care units includes
– Neurological observation
– Cerebral function monitoring
– Intracranial pressure monitoring

25. Neurological observation
• It includes -
Consciousness
Glasgow Coma Scale
Pupilary Assessment
Limb Movement

26. Consciousness
• Consciousness is the most sensitive indicator of neurological change and is
usually the first to be noted in neurological signs
• There are three properties of consciousness which can be
individually affected by the disease process. These are:
– Arousal or wakefulness (i.e. eyes open to command)
– Alertness and awareness (i.e. orientation and communication)
– Appropriate voluntary motor activity (i.e. obeying commands)
• Common methods of assessing conscious level are:
– AVPU
– Glasgow Coma Scale (GCS)

27. AVPU
A – Alert
V – Verbal
P – Pain
U – Unresponsive
Responds spontaneously
Responds to voice
Responds to pain stimuli
No response to verbal or pain
stimuli

28. Glasgow Coma Scale (GCS)
• The GCS Is a simple & standardised system to detect
changes in level of consciousness. It should be quick,
easy, objective & accurate.
• Head injury classification
Severe head injury
Moderate head injury
Minor head injury
GCS score of 8 or less
GCS score of 9–12
GCS score of 13–15

29. Pupilary Assessment
• Pupil size
– Normal pupils are round and equal in size, with an average size
of 2–5 mm in diameter.
– Pupil size scale on the neurological observation chart
. Reaction to light
• Pupil Documentation
– Pupil size should be recorded before proceeding to test pupil
response to direct light.
– + is used to indicate a brisk response
– - is used to indicate no response
– SL is used to indicate a 'sluggish' response
– C is used to indicate closed eyes due to periorbital oedema.

30. Limb Movement
• In this section you are assessing all limbs as opposed to the
best response in a limb, as in the GCS section.
• It is a combination of active and active resisted movements

31. Cerebral Function Monitoring
• Use of continuous EEG monitoring to assess and monitor a
patient with brain injury or acute ischemia enables prevention
of further complications.

32. Intracranial Pressure Monitoring
• Normal ICP is between 0 and 15 mm Hg.
• Intracranial pressure (ICP) monitoring is commonly used in patients with -
– Severe traumatic brain injury
– Intracranial hemorrhage
– Cerebral edema
– Post-craniotomy
• Contraindications
– Central nervous system infection
– Coagulation defects
– Anticoagulant therapy
– Scalp infection
– Severe midline shift resulting in ventricular displacement
– Cerebral edema resulting in ventricular collapse
• Complications
– Intracranial infection
– Intracerebral hemorrhage
– CSF leakage
– Over drainage of CSF leading to ventricular collapse and herniation.

33. RENAL SYSTEM MONITORING
• Fluids monitoring (in-put & out-put):
• The normal urinary output is 1 - 2 ml/kg/hr. Ideally it is
important to quantitate the urine output.
• In addition to quantitation of urine, it is also helpful to
quantitate defecation and emesis, this can provide you with a
better picture of your total fluid balance. Weight gains and
losses should be monitored on a daily basis if not more
frequently. Acute changes in weight are usually a result of
fluid changes and not muscle mass.

34. HEPATIC SYSTEM MONITORING
• Prothrombin time is a useful guide for the monitoring of liver
function.
• Factor vii has a half life of 4-8 hours and its measurement can
be used to assess the severity of coagulopathy.
• Greatly increased serum transaminase activity are
characteristic of hepatocellular demage, while raised alkaline
phospatase activity is seen in biliary obstruction.

35. HEMATOLOGICAL MONITORING
• Blood tests:
Common blood tests include blood chemisteries, glucose ,ABGs , CBC
cardaic markers , and coagulation tests.
ICU patients typically have routine daily blood tests to help detect
problems early.generally patients need a daily set of electrolytes and a cbc.
Patients with arrythmias should also have Mg, P and Ca levels measured.
Patients receiving TPN need weekly liver enzymes and coagulation
profiles.
• Hb and Hct concentration monitoring :
Low hct tends to be assosciated with improved perepheral perfusion.
Serial decline in hct indicates bleeding.
Ideal HCT in critically ill patient is probably 35% with a hb
concentration of 12-14 g/dL.