HEGAZY SURGERY

2. Presented By
Prof. Dr. Ibrahim El Ghazawy
2012

3. Monitoring of surgical patients
 Extends the capabilities of the surgeon.
 Improves patients’ outcome.
 Advances surgical science.
Aims

4. Haemodynamic monitoring
Indications:
 Continuous monitoring of blood pressure.
 Frequent sampling of arterial blood.
e.g.
 Shock (any aetiology).
 Acute hypertensive crisis.
 Use of vasoactive inotropic drugs.
 Respiratory support.
 High risk patients (extensive operations).
 Sequential analysis of blood gases, pH.
No absolute contraindications, except for specific sites
(infection, prosthesis, distal ischemia, ….).
1- Arterial catheterization:

5. Clinical utility of arterial catheterization
 Measure SBP.
 Measure DBP.
 Measure MAP.
 Pulse rate.
This reflects:
 Intravascular volume.
 Heart contractility.
 Vascular tree status
(periph. vascular resistance).

6. Sites of catheterization:
 Radial A (most common).
 Femoral A.
 Dorsalis pedis A.
 Superficial temporal A.
 Axillary A.
 Brachial A. (not used; inadequate collateral circ. Frequency of
catastrophic ischemic complication).
For radial A:
 Modified Allen test.
 Pulse oximetry.
 Doppler US.
Disadvantages:
 Mean, end diastolic p: accurate;
 SBP; overshoot (in stiff, arteriosclerotic A).

7. Axillary A:
Advantages:
 Large size.
 Close proximity to aorta.
 Accurate representation of aortic p. waveform.
 Minimal S.P. overshoot.
 Pulsations/ pressure are maintained even in
presence of shock (periph. vasoconstriction).
 Good collateral circ. bet. subclarian & distal
axillary A.
Clinical utility of arterial catheterization

8. Complications of Arterial Cannulation
 Failure to cannulate.
 Hematoma formation.
 Disconnection with bleeding.
 Radial A. thrombosis (use Teflon, smaller size: better)
use Heparin contin flow.
 Infections, (0 – 9%)
 factors: which ↑catheter infections.
Surgical cut-down.
Duration > 4 days.
 Retrograde cerebral embolization.
 A-V fistula.
 Pseudoaneurysm formation.

9. Central venous Catheterization
Indications:
 Access for fluid therapy.
 Drug infusions.
 Parenteral nutrition.
 CVP monitoring.
 Placement of cardiac pacemakers.
 IVC filters.
 Hemodialysis access.
Contraindications to specific site:
 Vessel thrombosis.
 Local infection inflammation.
 Trauma
 Previous surgery.

10. Clinical utility of central venous
catheter:
 Measure CVP. (DD: hypovolemia vs cardiac
tamponade
 CVP-tracing:
a-wave: absent in atrial fibrillation.
V-wave: prominent in tricuspid insufficiency.
 Measure:
Rt. atrial pressure, Rt. ventricle end-diastolic
pressure.

11. Sites of central venous catheterization:
 Subclarian V.
 Int. jugular V.
 Ext. Jug. V.
 Femoral V.
 Brachiocephalic V.
Subclavian V:
 Easy, high rate & success.
 Easy secure of catheter & dressing.
Disadvantages:
 Higher risk of penumothorax.
 Inability to compress vessel if bleeding occurs.
Internal jugular V:
 Easy cannulation, difficult in volume depletion.
 Easily compressed if bleeding occurs.

12. Complications of central venous catheterization
 Catheter malposition.
 Arrhythmias.
 Embolization.
 Vascular injury: (vessel laceration, hematoma, aneurysm, A-V
fistula).
 Cardiac injury (atrial, ventricular).
 Pleural injury (pneumothorax, hemothorax, hydrothx.)
 Mediastinal injury:
 Hydro-mediastinum. Hemomediastinum.
 Neurologic injury:
 Phrenic n. Rec. laryngeal n.
 Brachial plexus
 Others: trachea, thyroid, thoracic duct.
 Long-term: infection, sepsis, septicemia
 Thrombosis.

13. Pulmonary artery catheterization
Indications:
General:
 Shock, inspite of resuscitation.
 Oliguria, despite adequate fluid therapy.
 To assess cardiac performance.
 In MOF.
Surgical:
 Preoperative assessment of high risk patients.
 Cardiac/ major vasc. surgery.
 Multiple trauma.
 Severe burns.
Pulmonary:
 DD of non-cardiogenic (ARDS) from cardiogenic pulm. edema.
Cardiac:
 MI, with pump failure.
 Unstable angina with IV. nitroglycerin.
 CHF.
 Pulm. Hypertension.

14. Measurements obtained by pulmonary A. catheter
 CVP.
 PAD P.
 PAS P.
 MPAP.
 PAOP (wedge).
 Cardiac output.
 Mixed venous blood gases.
 LAP (balloon inflated).
Pulm. A. catheter is flow-directed. It passes into dependent
areas of the lung where blood flow is high and pulm. A,
venous P exceeds alveolar pressure.
 Thus: PAOP reflects LAP.
 LAP reflects LVEDP.
 LVEDP reflects LVEDV.

15. Complications of PA-catheter
 Dysrhythmias, (mostly not serious).
 BBB.
 Coiling of catheter, looping, knotting.
 Aberrant location: (pleural, pericardium,
peritoneal, aortic, renal vein).
 Rupture of PA. (most serious).
 Infections: bactermia: 0 – 4.6%.
 Thromboembolism.

16. Haemodynamic paramters
(by Pulm. A. catheter)
100 – 140 mmHg1- SBP
60 – 90 mmHg2- DBP
15 – 30 mmHg3- PASP
4 – 12 mmHg4- PADP
9 – 16 mmHg5- MPAP
15 – 30 mmHg6- RVSP
0 – 8 mmHg7- RVEDP
0 – 8 mmHg8- CVP
2 – 12 mmHg9- PAOP

17. Derived hemodynamic parameters
 MAP.
 Cardiac index (CI).
 Stroke volume (SV).
 Stroke index (SI).
 Left ventricular stroke work index (LVSW1).
 Right ventricular stroke work index (RVSW1)
 Systemic vascular Resistance (SVR).
 Pulmonary vascular resistance (PVR).
 Coronary perfusion P. (CPP).

18. Respiratory monitoring
Aim:
 To decide if mechanical ventilation
is indicated.
 Assess response to therapy.
 To decide if a weaning trial is
indicated.

19. Ventilation monitoring
Lung volumes:
Tidal volume:
 (VT): the volume of air moved in and
out of lungs in any single breath.
failureresp
ffrequencynrespiratio
.100
V
)(
T

weaningsuccessful80 
TV
f
IF:
IF:

20. Lung Volumes (CONT)
Vital capacity = (VC):
 The maximal expiration following a maximal inspiration.
 VC is reduced in diseases involving respiratory muscles,
in obstructive & restrictive diseases of lungs.
Minute volume (VE):
 Is the total volume of air leaving the lung each minute.
Dead space (VD):
 Is the portion of tidal volume that doesn’t participate in
gas exchange; 2 parts:
 Anatomical dead space.
 Alveolar dead space.

21. Blood gas analysis
Parameters
70 – 100 mmHg
o Arterial blood O2 tension
(PaO2)
> 92%
o Arterial hemoglobin O2
saturation (SaO2)
35 – 45 mmHg
o Mixed venous O2 tension
(PVO2)
65 – 80%
o Mixed venous hemoglobin O2
saturation (SVO2)
o O2 consumption
o O2 utilization coefficient
o Physiologic shunt
o Alveolar O2 tension

22. Respiratory Monitoring (Contin…)
Capnography:
 Is the graphic display of CO2
concentration as a waveform.
Capnometry:
 Is the numerical presentation of the
concentration of CO2 without a
waveform.

23. Pulse Oximetry:
 Measures arterial hemoglobin saturation, by
measuring the absorbance of light transmitted
through well-perfused tissue, such as finger or ear.
 The absorbance differs according to
oxyhemoglobin & deoxyhemoglobin.
Pulse-oximetry is influenced by:
 Hypotension  Hypovolemia
 Hypothermia  Vasoconstrictor infusions
 Motion artifact  Electrosurgical interference

24. Neurologic monitoring
Methods:
 Intracranial pressure monitoring.
 Electrophysiologic monitoring.
 Trans-cranial Doppler
ultrasonography.
 Jugular venous oximetry.

25. A) Intracranial pressure monitoring:
Indications of measurement of ICP:
 Severe head injury:
 GCS ≤ 8
 Or Motor Score ≤ 5
Value:
 Permits calculation of cerebral perfusion pressure (CPP)
CPP = MAP – ICP
 Thus increase of ICP or decrease of MAP will result in
decrease in CPP.
 Maintaining CPP at least 70 mmHg is just sufficient to
maintain adequate cerebral blood flow especially to
injured brain.

26. 2) Other indications to measure ICP:
 Subarachnoid hemorrhage.
 Hydrocephalus.
 Post-craniotomy.
 Massive strokes.
 Encephalitis.
 Post-cardiac arrest states.
Methods:
 Intraventricular catheter.
 Epidural catheter.
 Subarachnoid catheter.
Complications:
 Infection.
 Hemorrhage.
 Malfunction.
 Obstruction.
Neurologic monitoring

27. Electrophysiologic monitoring:
EEG (electro-encephalogram)
 To monitor the adequacy of cerebral
perfusion during carotid Endarterectomy.
 Cerebro-vascular surgery.
 Open heart surgery.
 Epilepsy.
Neurologic monitoring (contin…)

28. Transcranial Doppler
ultrasonography: (TCD)
 To monitor cerebral blood flow.
 It records blood flow-velocity in the basal
cerebral arteries.
 It detects vasospasm and it helps in
identification of hypremic/ low-flow areas.
Neurologic monitoring (contin…)

29. Glasgow Coma Score (GCS)
Eyes Open:
 Spontaneous 4
 To verbal command 3
 To painful stimulus 2
 Do not open 1
……………………………………........................
Verbal:
 Normal oriented conversation 5
 Confused 4
 Inappropriate words 3
 Sounds 2
 No sounds 1
 Intubated T
………………………………………………………
Motor:
 Obeys commands 6
 Localize pain 5
 Withdrawal/ Flexion 4
 Abnormal flexion (Decorticate) 3
 Extension (Decerebrate) 2
 No motor response 1

30. Jugular venous oximetry:
 An invasive method of continuous monitoring
of jugular venous bulb oxyhemoglobin
saturation.
 Readings of 55 to 71%: normal cerebral
perfusion
 Measurement < 50% is indicative of cerebral
ischemia.
Neurologic monitoring (contin…)

31. Temperature monitoring in ICUs:
To measure core temperature:
 Pulmonary A. thermistor catheter,
 Urinary B. thermistor catheter.
 Infra-red auditory canal probes.
 Esophageal core temperature measurement
by thermistor probes.
 Rectal core temperature by rectal probes.