Intensive care and anesthesia monitoring according to American scociety of anesthesiologist

1. BAS C
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MONITORINGEmad Zarief MD
A. Professor of Anesthesia & ICU dpt.
Faculty of Medicine , Assiut University
School of medicine , Windhoek

2. Monitor is a Latin word “to warn”
... interpret available clinical data to help recognize present or
future mishaps or unfavorable system conditions
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BAS C

3. ❖To maintain the normal patient physiology &
homeostasis To ensure the well being of the pt.
❖Surgery or trauma is a very stressful condition →
severe sympathetic stimulation, HTN, tachycardia,
arrhythmias.
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WHY?

4. ❖Most drugs used for general & regional anaesthesia cause
hemodynamic instability, myocardial depression,
hypotension & arrhythmias.
❖Under GA the pt. may be hypo or hyperventilated and
may develop hypothermia.
❖Blood loss → anaemia, hypotension. So it is necessary to
recognise when the pt. is in need of blood transfusion
(transfusion point).
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WHY?

5. Monitoring in the Past
Visual monitoring of
respiration and overall
clinical appearance
Finger on pulse
Blood pressure
(sometimes)
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6. STANDARD I
Qualified anesthesia personnel shall be present in the room
throughout the conduct of all general anesthetics, regional anesthetics
and monitored anesthesia care.
http://www.asahq.org/publicationsAndServices/standards/02.pdf
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BAS C

7. STANDARD II
Perioperatively , the patient’s :
❖Oxygenation,
❖Ventilation,
❖Circulation
❖Temperature
should be continually evaluated.
http://www.asahq.org/publicationsAndServices/standards/02.pdf
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BAS C

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Monitoring
of Circulation

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10. Tissue perfusion
▪Capillary refill <5 sec
▪Core temperature <5 diff from surface
▪Gastric mucosa pH
▪Acid base and Lactate
▪Mixed venous SvO2
▪Urine out put
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12. Systolic BP
Diastolic BP
Pulse Pressure
Mean Bp =
Indications
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13. Auto-regulation
means that the blood
flow of an organ
is kept constant
within a specific
range
of pressure .
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AUTOREGULATION

14. ❖Correct cuff size: width of the cuff should be 1.5 times limb
diameter and should occupy at least 2/3 of the arm.
❖2 cuff sizes for adult: blue: for most adult individuals (60-90 Kg),
red: for morbid obese.
❖Selection of appropriate cuff size is important because a tight cuff
leads to false high readings, while a Loose cuff gives false Low
readings.
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How to apply CUFF

15. NIBP
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16. Indications
sites
complications
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17. Indications of invasive BP.
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18. IBP
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20. ✓Heart rate.
✓Rhythm (arrhythmias) from lead II.
✓Ischemic changes & ST segment analysis.
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22. ◦On bony prominence.
◦AVOID hairy areas
◦Position them far away from each other to give e higher
voltage and better gain.
◦Ensure good contact with the skin: by using KY-Gel.
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23. ◦ QRS beep ON must be heard at all times. NO silent
monitors.
◦ clinical judgement is much more superior to the
monitor. Check peripheral pulsations.
◦ Arrythmias → check radial (peripheral) pulsations.
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24. LEADS
❖How many leads ?
❖Which lead(s) shall we
use for monitoring ?
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33. Central venous pressure
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34. CONTRAINDICATIOS OF
CENTRAL VENOUS LINE
APPLICATION?
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38. CVP
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✓ Non invasive
✓ Get pulse rate
✓ Rhythm
✓ Perfusion
✓ Saturation
✓ Pulse oximeter tone
changes with desaturation

42. waves
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43. plethysmography
detect only pulsatile blood waves ,so that not deal with venous or
capillary blood And only reads arterial blood !!
Saturation: using Infra red – and red light waves absorption reflection
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SPO2 = oxy HB / Oxy HB + Deoxy HB

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45. 1- No wave → don’t rely upon Spo2
2- you can use this correlation
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P O2 40 mmHg 50 mmHg 60 mmHg
Saturation % 70 80 90

46. RULES:
❖Keep the sound of the pulse oximeter ON at ALL times.
❖clinical judgement is much more superior to the monitor. Check pt
colour for cyanosis: lips, nails.
❖If hypoxemia occurs immediately check the correct position of the probe
on the pt and check the pts colour: nails & lips, then manage accordingly
& CALL 4 HELP.
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47. Fallacies & Inaccuracies occur when:
◦ Misplaced on the pts finger, slipped.
◦ Pt movement, shivering.
◦ Poor tissue perfusion (cold extremities, hypotension & shock).
◦ Carboxy HB , Mythelene blue … etc
◦ Sometimes by electrical interference from cautery in some monitors.
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Temperature
monitoring

49. Clinical monitoring: by hands.
Monitors: temperature probe. nasopharyngeal, esophageal.
AVOID hypothermia < 36oC. Why? & How?
(Especially in extremes of age).
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Temperature
monitoring

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Temperature
monitoring

51. Respiratory Monitors:
O2 Saturation.
Capnography EtCO2.
Airway pressure.
ABG samples.
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52. Continuous CO2 measurement displayed as a waveform sampled
from the patient’s airway during ventilation.
◦What is EtCO2?
A point on the capnogram. It is the final measurement at the
endpoint of the pts expiration before inspiration begins again. It
is usually the highest CO2 measurement during ventilation.
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54. Capnography
Sudden loss of waveform
Esophageal intubation
Ventilator disconnect
Ventilator malfunction
Obstructed / kinked ETT
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55. Capnography
Decrease in waveform
Sudden hypotension
Massive blood loss
Cardiac arrest
Hypothermia
PE
CPB
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56. Capnography
Gradual increase in waveform
Increased body temp
Hypoventilation
Partial airway obstruction
Exogenous CO2 source (w/laparoscopy/CO2 inflation)
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57. Capnography
Cleft in alveolar plateau
Partial recovery from neuromuscular blockade
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58. Factors affecting EtCO2: what ↑ what ↓ EtCO2?
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59. LISTEN
Listen to the monitor the whole time:
◦ To the pulse oximeter tone to identify: 1-Heart rate 2- Spo2
from the tone (pitch) of pulse oximeter.
◦ To the sound of the ventilator, to any abnormal sounds, any alarms.
RULE: NO silent monitors. ALWAYS keep the HR sound on. If ur
monitor is silent (sound is not working) u have to look at your
monitor the WHOLE time.
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60. NEVER
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