Intra-operative monitoring during anesthesia

1. MONITORING DURING ANESTHESIA
Dr Sandeep Kundra
Department of Anesthesia
DMC & H, Ludhiana.

2. WHY IS MONITORING REQUIRED
 To maintain normal homeostasis throughout surgery: so as to ensure
the well being of the pt.
 Surgery is a very stressful condition → severe sympathetic stimulation,
HTN, tachycardia, arrhythmias.
 Most drugs used for general & regional anesthesia cause hemodynamic
instability, myocardial depression, hypotension & arrhythmias.
 Under GA the pt may be hypo or hyperventilated and may develop
hypothermia.
 Blood loss → anemia, hypotension. So it is necessary to recognise
when the pt is in need of blood transfusion (transfusion point).

3. The most primitive method of monitoring the patient 25 years
ago was continuous palpation of the radial pulsations
throughout the operation!!

4. MODERN MONITORING
 Many integrated monitors available
 Many special purpose monitors available
Transesophageal
Echocardiography
Depth of Anesthesia Monitor
Evoked Potential Monitor

5. STANDARD
ASA monitoring for general anesthesia , monitored anesthesia care and
regional anesthesia :-
 Oxygenation (oxygen analyzer, pulse oximetry),
 Ventilation (capnography, minute ventilation), respiratory rate (under
regional anesthesia)
 Circulation (electrocardiogram [ECG], arterial blood pressure, perfusion
assessment),
 Temperature.
We are NOT authorised to start a surgery in the absence
of any of these monitors:

6. PULSE OXIMETER-- SPO2
 Most commonly used monitor.
 Definition: % of oxy-Hb / oxy + deoxy-Hb.
 Timing of SpO2 monitoring: throughout the surgery:
 Waveform of pulse oximeter = plethysmograph (arterial waveform).
 Without the waveform pulse oximeter readings are unreliable &
incorrect.

7. INTRAOPERATIVE MONITORING: SPO2
 How to attach/apply saturation probe:
 To the finger or toe (if finger is not accessible). The red light is
applied to the nail. Nail polish and stains should be removed
→ false readings and artefacts.
 Can also be applied to the ear lobe.
 In infants and children can be applied to 2 fingers or to the
hand.
 Usually attached to the limb with the IV line (opposite the limb
with the blood pressure cuff).

8. PULSE OXIMETER………WORKING PRINCIPLE
Two LED’s emit monochromatic light

9. PULSE OXIMETER………WORKING PRINCIPLE
Oxy Hb absorbs more infra red light @ 900 nm
Deoxy Hb absorbs more Red Light @ 650 nm

10. INTRAOPERATIVE MONITORING: SPO2
 Value:
 SpO2: arterial O2 saturation (oxygenation of the pt).
 HR.
 Peripheral perfusion status.
 Gives an idea about the rhythm from the plethysmography wave
(arterial waveform).
 Cardiac arrest.
 Pulse oximeter tone changes with desaturation from high pitched to
low pitched (deep sound).

12. INTRAOPERATIVE MONITORING: SPO2
Readings:
 Normal person on room air (O2 = 21%) ˃ 96%.
 Patient under GA (100% O2) = 98-100%.
 It is not accepted for O2 saturation to ↓ below 96% with 100% O2
under GA. Must search for a cause.
 < 90% = hypoxemia.
 < 85% = severe hypoxemia.

13. INTRAOPERATIVE MONITORING: SPO2
 Fallacies & Inaccuracies occur when:
 Misplaced on the pts finger, slipped.
 Pt movement, shivering.
 Poor tissue perfusion (cold extremities, hypotension & shock)
 Dyshemoglobinemia.
 Sometimes by electrical interference from cautery.
 Optical Interference.

14. CAPNOGRAPHY
Capnography -- Continuous CO2 measurement displayed as a
waveform sampled from the patient’s airway during ventilation.

15. INTRAOPERATIVE MONITORING: CO2
 Phases of the capnogram:
Balseline: A-B
Upstroke: B-C
Plateau: C-D
End-tidal: point D
Downstroke

16. PHASES OF CAPNOGRAM
Alveolar air

17. INTRAOPERATIVE MONITORING: CO2
 Normal range: 30-35 mmHg. (Usually lower than arterial PaCO2 by
5-6 mmHg due to dilution by dead space ventilation).
 Value (data gained from capnography & ETCO2):
 ETT: esophageal intubation.
 Ventilation: hypo & hyperventilation, curare cleft (spontaneous
breathing trials).
 Pulmonary perfusion: pulmonary embolism.
 Breathing circuit: disconnection, kink, leakage, obstruction,
unidirectional valve dysfunction, rebreathing, exhausted soda lime.
 Cardiac arrest: adequacy of resuscitation during cardiac arrest, and
prognostic value (outcome after cardiac arrest).

18. INTRAOPERATIVE MONITORING: CO2

19. CLINICAL APPLICATIONS

20. ECG

21. INTRAOPERATIVE MONITORING: ECG
Value:
 Heart rate.
 Rhythm (arrhythmias) usually best identified from lead II.
 Ischemic changes & ST segment analysis.
• Does NOT indicate mechanical performance of the heart:
– Cardiac output
– Tissue perfusion
Timing of ECG monitoring: Throughout the surgery: before
induction until after extubation & recovery.

24. INTRAOPERATIVE MONITORING: ECG
 How to attach ECG electrodes:
 Choose a bony prominence. Avoid fatty regions
 AVOID hairy areas(shave if reqd in hairy persons).
 Position them far away from each other to give a higher voltage
and better gain.
 Ensure good contact with the skin: use KY-Gel.
 If the electrodes would not be accessible during the surgery or
will be soaked in betadine, after ensuring good ECG trace cover
the stickers with adhesive tape.

25. INTRAOPERATIVE MONITORING: ECG
If the EGC gives no trace (noise):
follow ECG cable from the pt to the monitor:
 Ensure good contact with the pt: non-hairy areas, apply KY-
Gel, search for slipped or loose electrodes.
 Ensure proper fitting of cable connections.
 Ensure proper fitting of the cable to the monitor.
 Change monitor settings: try different leads (I, II, III, avR, avR,
avL, V1-6), filter, size (amplitude) of ECG.
 Ensure earthing of the monitor (earth cable from behind).

26. Artifacts in ECG Monitoring
• Loose electrodes or broken leads
• Misplaced leads
• Wrong lead system selected
• Emphysema, pneumothorax, pericardial effusion
• Shivering or restlessness
• Respiratory variation and movement
Monitor Pulse Oximetry, Invasive ABP

27. BLOOD PRESSURE

28. INTRAOPERATIVE MONITORING: NIBP
 NIBP: (non-invasive ABP monitoring = automated). Gives readings
for: systolic BP, diastolic BP & MAP: Systolic/ diastolic (mean).
 Value: to avoid and manage extremes of hypotension & HTN.
Systolic BP-Diastolic BP- MAP.
 Avoid ↓ MAP < 60 mmHg (for cerebral & renal perfusion) & avoid ↓
diastolic pressure < 50 mmHg (for coronary perfusion).

29. INTRAOPERATIVE MONITORING: BP
 Timing of BP monitoring: throughout the surgery: before induction
till after extubation & recovery.
 Frequency of measurement:
 By default every 5 minutes.
 Every 3 minutes: immediately after spinal anesthesia, in
conditions of hemodynamic instability, during hypotensive
anesthesia.
 Every 10 minutes: eg. In awake pts under local anesthesia:
“monitored anesthesia care” (minimal hemodynamic changes).

30. INTRAOPERATIVE MONITORING: (3) BP
How to attach/apply:
 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.

31.  Is better applied directly to the arm (remove sleeve). May also be
applied to the forearm in very obese individuals. May be applied to
the calf if the arms are not accessible during surgery.
 Correct positioning: cuff is positioned with the hoses over the
brachial artery.
 Usually attached to the limb opposite the IV line & pulse oximeter.
 AVOID attaching it to an arm with A-V graft (for renal dialysis) →
damage of AV graft, & inaccurate measurements.

32. INTRAOPERATIVE MONITORING: BP
Reading Error/failure:
 Pressure line is disconnected.
 Leakage from damaged cuff.
 Line is compressed (under someone’s foot or under a weal).
 Line contains water from washing!
 Monitor error: cuff cannot inflate due to infant or neonate limits.

33. INTRAOPERATIVE MONITORING: BP
 Palpation of Radial A → systolic BP ˃ 90 mmHg.
 Palpation of Dorsalis Pedis A → systolic BP ˃ 80 mmHg.
 Palpation of Superficial Temporal A → systolic BP ˃ 80 mmHg.
 i.e If Radial A pulsations are lost = systolic BP is < 90 mmHg.
 If dorsalis pedis & superficial temporal pulsations are lost = systolic
BP is < 80 mmHg.

34. INTRAOPERATIVE MONITORING: BP
IBP: (invasive arterial blood pressure monitoring)
 It is beat to beat monitoring of ABP via an arterial cannula.
 Indicated in: major surgeries, during deliberate hypotensive
anesthesia, during the use of inotropes, cardiac surgery, in surgeries
involving extreme hemodynamic changes/instability eg.
pheochromocytoma, repeated ABG sampling.

36. URINE OUTPUT
Indications:
1) lengthy surgery ˃ 4 hrs
2) major surgery with major blood loss
3) C-section: to monitor injury to the bladder or ureter.
Normal: 0.5-1 ml/kg/hr.
Note the baseline urine volume at the start of operation.
Management of oliguria or anuria:
 Check that the line is not kinked or disconnected.
 Palpate the urinary bladder (suprapubic fullness)
 Raise BP (MAP ˃ 80 mmHg): renal perfusion.
 IV fluid challenge.
 Diuretics.
 N.B. Sometimes trendlenberg position (head down) causes ↓ UOP.
Reversal of this position results in immediate flow of urine.

37. CNS: AWARENESS
Clinical monitoring:
Signs of pt awareness:
 Movement, grimacing (facial expression).
 Pupils dilated.
 Lacrimation.
 Tachycardia.
 HTN.
 Sweating: is always an alarming/warning sign. Causes:
 Awareness.
 Hypoglycemia.
 Hypercapnia.
 Thyroid storm (thyrotoxic crisis).
 Fever.
 Always check the concentration of ur vaporizer &
make sure that ur vaporizer is not empty (below
minimum = gives a concentration lower than adjusted).

38. CNS MONITORING
(LEVEL OF CONSCIOUSNESS)
 Bispectral index (BIS) assess central nervous system
depression during general anesthesia.
 It is based on the surface electroencephalogram (EEG), which
predictably changes in amplitude and frequency as the depth
of anesthesia increases.

39. TEMPERATURE MONITORING
 Monitors: temperature probe: nasopharyngeal, esophageal.
 AVOID hypothermia < 36oC. Why? & How?
 Especially in pediatrics & geriatrics (extremes of age).
 Complications of hypothermia):
 Cardiac arrhythmias: VT & cardiac arrest.
 Myocardial depression.
 Delayed recovery (delays drug metabolism).
 Delayed enzymatic drug metabolism.
 Metabolic acidosis (tissue hypoperfusion → anerobic glycolysis →
lactic acidosis) & hyperkalemia.
 Coagulopathy.

40. NEUROMUSCULAR BLOCKADE
MONITORING:
 Neuromuscular blockade is monitored during surgery to guide
repeated doses of muscle relaxants and to differentiate
between the types of block.
 All techniques for assessing neuromuscular blockade use a
peripheral nerve stimulator (PNS) to stimulate a motor nerve
electrically.

42. To Summarize:
“How do I monitor the patient in OR?”
The 4 basic monitors displayed on the screen:
1) ECG.
2) BP.
3) SpO2.
4) Capnogram (EtCO2).

43. RULES NEVER TO FORGET:
 Never start induction with a missing monitor: ECG, BP, SpO2.
 Never remove any monitors before extubation & recovery.
 NEVER ignore an alarm by the ventilator.
 ALWAYS remember than ur clinical sense & judgement is better
than & superior to any monitor.
 ALWAYS remember that there is NO such thing as “all monitors
disconnected” Immediately check peripheral & carotid
pulsations.

44. THE BEST AND THE MAIN
MONITOR IN THE OPERATING
ROOM
IS

45. ALWAYS AN
ANESTHESIOLOGIST

46. PACU - ASA STANDARDS
1. Standard I
All patients should receive appropriate care
2. Standard II
All patients will be accompanied by one of anesthesia team
3. Standard III
The patient will be reevaluated & report given to the nurse
4. Standard IV
The patient shall be continually monitored in the PACU
5. Standard V
A physician will be signing for the patient out of the PACU

47. PATIENT CARE IN THE PACU
 Admission
 Apply oxygen and monitor
 Receive report
 Monitor & Observe & Manage
 To Achieve
 Cardiovascular stability
 Respiratory stability
 Pain control
 Discharge from PACU

48. MONITORING IN THE PACU
 Baseline vital signs.
 Respiration
 RR/min, Rythm
 Pulse oximetry
 Circulation
 PR/min & Blood pressure
 ECG
 Level of consciousness
 Pain scores

49. INITIAL ASSESSMENT
1. Color
2. Respiration
3. Circulation
4. Consciousness
5. Activity

50. COMMON PACU PROBLEMS
 Airway obstruction
 Hypoxemia
 Hypoventilation
 Hypotension
 Hypertension
 Cardiac dysrhythmias
 Hypothermia
• Bleeding
• Agitation
• Delayed recovery
• “PONV”
• Pain
• Oliguria

51. 1. AIRWAY OBSTRUCTION
 Most common: tongue fall back
 posterior pharynx
 May be foreign body
 Inadequate relaxant reversal
 Residual anesthesia

52. MANAGEMENT OF AIRWAY OBSTRUCTION
 Patient’s stimulation,
 Suction,
 Oral Airway,
 Nasal Airway,
 Others:
 Tracheal intubation
 Cricothyroidotomy
 Tracheotomy

53. 2. HYPOVENTILATION
 Residual anesthesia
 Narcotics
 Inhalation agent
 Muscle Relaxant
 Post oper - Analgesia
 Intravenous
 Epidural

54. TREATMENT OF HYPOVENTILATION
 Close observation,
 Assess the problem,
 Treatment of the cause:
 Reverse (or Antidote):
Muscle relaxant  Neostigmine
Opioids  Naloxone
Midazolam  Flumazenil

55. 3. HYPERTENSION
 Common causes: e.g.
 Pain
 Full Bladder
 Hypertensive patients
 Fluid overload
 Excessive use of vasopressors

56. TREATMENT OF HYPERTENSION
 Effective pain control
 Sedation
 Anti-hypertensives:
 Beta blockers
 Alpha blockers
 Hydralazine (Apresoline)
 Calcium channel blockers

57. 4. HYPOTENSION
 Decreased venous return
 Hypovolemia,
 fluid intake
 losses
Bleeding
 Sympathectomy,
 3rd space loss,
 Left ventricular dysfunction

58. TREATMENT OF HYPOTENSION
 Initially treat with fluid bolus,
 + Vasopressors,
 + Correction of the cause

59. 5. DYSRHYTHMIAS
 Secondary to
 Hypoxemia
 Hypercarbia
 Hypothermia
 Acidosis
 Catecholamines
 Electrolyte abnormalities.

60. TREATMENT OF DYSRHYTHMIA
 Identify and treat the cause,
 Assure oxygenation,
 Pharmacological

61. 6. URINE OUTPUT
 Oliguria
 Hypovolemia,
 Surgical trauma,
 Impaired renal function,
 Mechanical blocking of catheter.
 Treatment:
 Assess catheter patency
 Fluid bolus
 Diuretics e.g. Lasix

62. 7. POST OP BLEEDING
Causes:
 Usually Surgical
Problem,
 Coagulopathy,
 Drug induced

63. TREATMENT OF POST OP BLEEDING
Wide bore IV cannula  push fluids
• Blood sample,
- CBC,
- Cross matching,
- Coagulopathy
• Notify the surgeon,
• Correction of the cause

64. 8. HYPOTHERMIA
 Most of patients will arrive cold
 Treatment:
 Get baseline temperature
 Actively rewarm
 Administer oxygen if shivering
 Take care for:
Pediatric,
Geriatric.

65. 9. POSTOPERATIVE NAUSEA &
VOMITING “PONV”
 Risk factors
 Type & duration of surgery,
 Type of anesthesia,
 Drugs,
 Hormone levels,
 Medical problems,
 Autonomic involvement.

66. PREVENTION OF PONV
 NPO status
 Dexamothasone,
 Droperidol,
 Metoclopramide,
 H2 blockers,
 Ondansetron,
 Acupuncture

67.  Chief concern of patient.
 Inadequate treatment results in patient dissatisfaction, delayed
healing and evolution into chronic pain.
 Patient sleeps ---- only then you can sleep!!!!
 Still post-op pain is inadequately managed in upto 60 % of
patients.
12. Postoperative Pain

68. Numeric Rating Scale (NRS)
Visual Analogue Scale (VAS)
0 10
Post-op Pain -- Assessment

69. Wong-Baker “Faces Scale”
Verbal scale
No
Pain
Mild Moderate
Severe
Pain

70. WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
Severe pain (7-10)
± Adjuvant
± Adjuvant
± Adjuvant
WHO IV Interventional
By the mouth
By the clock
By the ladder
WHO LADDER
UPDATED
WHO class II Weak opioids
WHO class I NSAIDs

71. PHARMACO - THERAPY
1. Local infiltration
2. Wound perfusion
3. Intra-abdominal inj. of
LA/Analg.
4. Intercostal & Interpleural
5. Paravertebral
6. USG-RA: e.g. TAP
7. Neuraxial:
 Epidural:
 Thoracic
 Lumbar
 Spinal
 Single shot
 CSA
 CSE
1. Non Opioid Analgesics
 NSAADs
 Analgesic /Antipyretic
 Analgesic/Anti-
inflam/Antipyretic
 NSAIDs
 Non-selective COX inhibitors
 Selective COX-2 inhibitors
2. Opioids
 Weak Opioids.
 Strong Opioids.
 Mixed agonist-antagonists
3. Adjuvants
 -2 Agonists
 LA
 NMDA inhibitors
 Anticonvulsant / Antidepressants
 Relaxants
Regional Techniques
ACUTE POSTOPERATIVE MANAGEMENT TOOLS

72. PACU DISCHARGE CRITERIA
 Fully Awake,
 Patent airway,
 Good respiratory function,
 Stable vital signs,
 Patency of tubes, catheters, IV’s
 Pain free,
 Reassurance of surgical site.

73. ALDRETE SCORE
Score Activity Respiratio
n
Circulatio
n
Consciousnes
s
Oxygen
Saturation
2 Moves all
extremities
Breaths
deeply and
coughs
freely.
BP + 20
mm of
preanesth.
level
Fully awake Spo2 > 92%
on room air
1 Moves 2
extremities
Dyspneic, or
shallow
breathing
BP + 20-50
mm of
preanesth.
level
Arousable on
calling
Spo2 >90%
With suppl.
O2
0
Unable to
move
Apneic
BP + 50
mm of
preanesth.
level
Not
responding
Spo2 <92%
With suppl.
O2

74. POSTANESTHESIA DISCHARGE SCORING
SYSTEM
Sco
re
Vital Signs
(PR & ABP)
Activity PONV Pain Surgical
Bleeding
2
Within 20% of
preoperative baseline
Steady gait,
no dizziness
Minimal: treat
with PO meds
Acceptable
control per the
patient;
controlled
with PO meds
Minimal: no
dressing
changes
required
1
20-40% of preoperative
baseline
Requires
assistance
Moderate:
treat with IM
medications
Not
acceptable to
the patient;
not controlled
with PO meds
Moderate: up
to 2 dressing
changes
0
>40% of preoperative
baseline
Unable to
ambulate
Continues:
repeated
treatment
Severe
Uncontrolled
pain
Severe: more
than 3
dressing
changes

75. WE WATCH WHILE YOU SLEEP

77. QUESTION NO. 1
 1- Identify the monitor Tracing?

………………………………………
 2- What is the Name & Cause of
the Notch on the descending
limb of the trace?
 ………………………………
………………………………………
………
 3- Name two different Clinical
informations could be
interpreted from this tracing?
 a) ……………………………..
 b) ……………………………..

78. QUESTION NO. 2
1- Identify the Rhythm in the shown ECG Strip?
------------------------------------------------------
2- What is your first line of management in case of
Unstable patient
…………………………………………………………
3- What is the normal QRS duration
……………………………………………………………

79. QUESTION NO. 3
1- Identify the tracing
……………………………………………………
…………………………………
2- Name the different phases of the trace
I  ………………………
II  ……………………..
III  …………………….
IV  ……………………..
3- What different clinical informations could
be interpreted from the trace
a) ………………………………………………..
b) ………………………………………………..

80. QUESTION NO. 4
1- Name the different waves on the trace?
------------------------------------------------
2- Define Central Venous Pressure?
……………………………………………………
……………………………………………………
3- What are the main determinants regulating
CVP?
A-………………………………….
B- ………………………………...

81. QUESTION NO. 5
brief the mechanism of action of this monitor :
………………………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
…
Name 4 factors affecting the accuracy of this monitor?
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
If P50 of oxyhemoglobine dissociation curve is 40; is this curve shifted
to the right or left; mention 3 possible causes?
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………..

82. Q 6-Each of the following factors may lead to
error in readings using pulse oximetry EXCEPT:
A. electrocautery
B. high cardiac output states
C. infrared lights near the sensor
D. intravenous dyes
E. severe hemodilution

83. Q 7: What is Beer’s Law?
Ans: Amount of light absorbed is proportional to the
concentration of the light absorbing substance.
Q 8: What is Lambert’s law?
Ans: Amount of light absorbed is proportional to the
length of the path that the light has to travel in the
absorbing substance.

84.  Q 9: With regards to capnograph, What is α-
angle. What is its normal value and what does it
signify.
 Q 10 What is β- angle and its normal value.

85. The Alpha angle
 The angle between phases II and III, which
has
 increases as the slope of phase III
increases.
 The alpha angle is an indirect indication of
V/Q
 status of the lung.
 Airway obstruction causes an increased
 slope and a larger angle.
 Other factors that affect the angle are the
response time of the capnograph, sweep
speed, and the respiratory cycle time.
The Beta angle
 The nearly 90 degrees angle between phase III
and the descending limb in a time capnogram
has been termed as the beta angle.
 This can be used to assess the extent of
rebreathing. During rebreathing, there is an
increase in beta angle from the normal 90
degrees.

86. HOW ?
 An anesthesiologist could monitor whole of patient’s
condition and follow the course of surgery,
anticipating problems and correcting them as and
when they occur.
 Continuously integrates subjective(visual, tactile,
auditory) and objective information from
anesthetized subject.

87.  Even the most sophisticated electronic monitors are
inherently limited and they monitor only one aspect
of the patient’s condition.
 Require electrical power
 Need regular maintenance.
 Occasionally develops faults
 Prone to error
By contrast,

88. ADVANTAGE IS
 They do not succumb to
Stress
Boredom
Fatigue
Distraction !!!!

89. HOWEVER !!
Not possible for the anesthesiologist to be completely vigilant at
all times.
MONITORS do not “replace”the anesthesiologist ,
BUT
EXTEND THEIR RANGE AND SOMETIMES
ACCURACY
Free our hands to perform other important tasks
(maintaining airway, preparing drugs, etc.)
Only way of observing inaccessible patients during
MRI or CT scan.

90. PITFALLS OF MONITORS
• Over-reliance upon monitors
• Faulty equipment / data
• Complications from invasive monitoring
• Constantly sounding alarms
• Distracts anaesthetist from patient

91. (1) ECG

92. ARTERIAL BLOOD PRESSURE.
 Automated noninvasive blood pressure is the most common
noninvasive method of measuring blood pressure in the
operating room.
 Invasive blood pressure monitoring uses an indwelling arterial
catheter coupled through fluid-filled tubing to a pressure
transducer.
 The transducer converts pressure into an electrical signal to
be displayed.
 Indications
Need for tight blood pressure control (e.g., induced
hyper- or hypotension).
Hemodynamically unstable patient.
Frequent arterial blood sampling.
Inability to utilize noninvasive blood pressure
measurements.

93. ARTERIAL BLOOD PRESSURE

94. TEMPERATURE MONITORING
Indications
Infants and small children are prone to thermal lability due to
their high surface area to volume ratio.
Adults subjected to large evaporative losses or low ambient
temperatures (as occur with exposed body cavity, large
volume transfusion of unwarmed fluids, or burns) are prone
to hypothermia.
Malignant hyperthermia is always a possible complication, and
temperature monitoring should always be available.

95. Monitoring site
Tympanic membrane temperature
Rectal temperature
Nasopharyngeal temperature,
Esophageal temperature monitoring reflects the
core temperature well. The probe should be
located at the lower third of the esophagus and
rarely may be misplaced in the airway.
Blood temperature measurements may be
obtained with the thermistor of a PAC.

96. OXYGEN SATURATION ….. WHAT DOES IT
MEAN

97. PULSE OXIMETER-- SPO2

98. INDIVIDUAL SYSTEM MONITORING
 Position of ETT.
 Respiratory System.
 CVS & Hemodynamic Monitoring.
 CNS: Awareness.
 Temperature.
 Monitoring after Extubation & Recovery.

99. CORRECT POSITION OF ETT

100. CORRECT POSITION OF ETT
 After intubation Auscultation MUST be done in 5 areas:
► Rt & Lt infraclavicular.
► Rt & Lt axillary.
► EPIGASTRIUM: to exclude esophageal intubation.
 We MUST ALWAYS auscultate the chest after intubation for:
- Equal air entry: to exclude endobronchial intubation.
- Adventitious sounds: wheezes, crepitations, pulmonary edema.
 We MUST ALWAYS auscultate the chest AGAIN after repositioning to
exclude:
 Inward displacement → endobronchial intubation.
 Outward displacement → slippage & accidental extubation.

101. RESPIRATORY MONITORING
Respiratory Monitors:
 O2 Saturation.
 Capnography EtCO2.
 Airway pressure.
 ABG samples.

102. RESPIRATORY MONITORING
 N.B. Various alarms by the ventilator:
NEVER ignore an alarm by the ventilator!
 Low airway pressure: leakage, disconnection.
 High airway pressure: kink, biting of the tube, bronchospasm,
slipped → esophagus.
 Low expired tidal volume: leakage.
 Apnea alarm: disconnection.
 O2 sensor failure: (unfortunately common in many of our
ventilators).
 Flow sensor failure: (unfortunately common in many of our
ventilators).

103. CVS HEMODYNAMIC MONITORING
CVS Monitors:
 ECG.
 Blood pressure (NIBP, IBP).
 Central Venous Pressure: value: indicator of:
1) IV volume.
2) RV function.
 Advanced Monitoring uncommonly used:
ECHO, TEE, SVV, CO monitoring

104. 9. ALTERED MENTAL STATUS
 Reaction to drugs?
 Drugs e.g. sedatives, anticholinergics
 Intoxication / Drug abusers
 Pain
 Full bladder
 Hypoventilation
 Low COP
 CVA

105. TREATMENT OF ALTERED MENTAL
STATUS
 Reassurances,
 Always protect the patient,
 Evaluate the cause,
 Treatment of symptoms,
 Sedatives / Opioids if necessary.

106. 10. DELAYED RECOVERY
 Systematic evaluation
 Pre-op status
 Intraoperative events
 Ventilation
 Response to Stimulation
 Cardiovascular status

107. DELAYED RECOVERY
 The most common cause:
 Residual anesthesia  Consider reversal
 Hypothermia,
 Metabolic e.g. diabetic coma,
 Underlying psychiatric problem
 CVA

108. 1. Non Opioid Analgesics
 NSAADs
 Analgesic / Anti-inflam / Antipyretic / Anticoagulant
 ASA
 Analgesic /Antipyretic
 Paracetamol
 NSAIDs
Non-selective COX inhibitors:
 Diclofenac & Ketoprofen
Selective COX-2 inhibitors
 Celecoxib & Rofecoxib
WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
Mild pain
(0-3)
Moderate pain (4-6)
± Adjuvant
± Adjuvant
± Adjuvant
Severe pain (7-10)

109. SCIENTIFIC EVIDENCE – NON OPIOID ANALGESICS
1. Paracetamol:
1. is an effective analgesic for acute pain; the incidence of adverse
effects comparable to placebo (Level I [Cochrane Review]).
2. Paracetamol / NSAIDs given in addition to PCA Opioids  
Opioid consumption (Level I).
2. NSAIDs:
1. are effective in the treatment of acute postoperative (Level I ).
2. With careful patient selection and monitoring, the incidence of
renal impairment is low (Level I [Cochrane Review]).
3. NSAIDs + Paracetamol improve analgesia compared with
paracetamol alone (Level I).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

110. WHO LADDER II - WEAK OPIOIDS:
1. Tramadol:
 Tramadol : Morphine:
 Parenteral = 1 : 10 & Oral = 1 : 5
 Dose: 200 – 400 mg/d
2. Codeine:
 Metabolized to morphine.
 Codeine : Morphine = 1 : 10
3. Dextro-propoxyphene:
 Methadone Derivative
 Prolongation of Q-T interval.
WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
Mild pain
(0-3)
Moderate pain (4-6)
± Adjuvant
± Adjuvant
± Adjuvant
Severe pain (7-10)

111. SCIENTIFIC EVIDENCE – WEAK OPIOIDS
1. Tramadol:
 has a lower risk of respiratory depression & impairs GIT
motor function < other opioids
(Level II).
 is an effective treatment for neuropathic pain
(Level I [Cochrane Review]).
2. Dextropropoxyphene:
 has low analgesic efficacy
(Level I [Cochrane Review]).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

112. WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
Mild pain (0-
3)
Moderate pain (4-6)
± Adjuvant
± Adjuvant
± Adjuvant
WHO LADDER III - STRONG OPIOIDS
1. Morphine:
1. Sedation
2. PONV
3. Respiratory Depression
2. Fentanyl
1. Rapid action, Short duration.
2. Fentanyl : Mophine = (1:10)
3. Pethidene:
1. Active metabolite:  t½ .
2. Prolongs Q-T interval.
3. Pethidine : Mophine = (1:10)
4. Hydromorphone:
1. Powerful, rapidly acting.
2. Release is in distal gut.
3. Hydromorphone : Morphine = 1 : 5
Severe pain (7-10)

113. WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
Severe pain (7-10)
± Adjuvant
± Adjuvant
± Adjuvant
WHO IV Interventional
WHO class II Weak opioids
WHO class I NSAIDs
WHO Ladder IV – Regional Anesthetic
Techniques
1. Local infiltration
2. Wound perfusion
3. Intra-abdominal LA
4. Intercostal
5. Interpleural
6. Paravertebral
7. USG - RA: e.g. TAP
8. Neuraxial:
 Epidural:
 Thoracic
 Lumbar
 Spinal
 Single shot
 CSA
 CSE

114. NEURAXIAL (SPINAL / EPIDURAL)
(LA / OPIOIDS / OTHERS)
 Advantages:
 Provide prolonged & effective analgesia
 Side effects
 Respiratory depression.
 N/V.
 Pruritis.
 Urinary retention.

115. + Multidisciplinary:
• Adjuvant therapy.
• Psychotherapy.
• Physioltherapy.
• Causal diag. & ttt.
WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
LA infiltration
Non-pharmacological
Paravertebral / PNB
Neuraxial LA
Opioids
WHO Algorithm for Management of
Pain
Plexus block

116. Diagnosis
Procedure Specific
Pain manag. Pain Assessment
Preventive /
Preemptive
ttt of Pain and Co morbidities
1ry Treatment Supportive Treatment
Pharmacotherapy
Interventional
Psychological ttt.
Physical / Rehab.
Management Algorithm for Postoperative Pain

117. Subjective Objective
Uni-Dimensional Multidimentional  Behavioral.
 Physiological.
 Neuro-endocrinal.
 Algometry.
 VRS, VAS & NRS.
 Facial expression.
 McGill P Q,
 Pain Inventory.
 ACUTE PAIN  Chronic Pain  Both
PAIN MEASUREMENTS

118. INTRAOPERATIVE MONITORING: SPO2
RULES:
 Keep the sound of the pulse oximeter ON at ALL times.
 Pay attention to the sound of the pulse oximeter. NO silent
monitors.
 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.