This document discusses patient safety and monitoring in anesthesia. It covers key topics like ensuring patient safety in anesthesia, important parameters to monitor such as ECG, SpO2, blood pressure, end tidal CO2 and temperature. It discusses the importance of continuous monitoring and vigilance to prevent adverse events. It also covers hypothermia and hyperthermia, noting complications of each, and how to prevent and treat hypothermia with warming measures. Malignant hyperthermia, a rare inherited disorder triggered by certain anesthetics, is also summarized.

1. PATIENT SAFTEY AND MONITORING
Gradian Health Systems
Simulation-Based Product Training

2. Agenda
2
I. Patient Safety in Anesthesia
II. Patient Monitoring
III. Hypothermia vs Hyperthermia
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3. I. Patient Safety in Anesthesia
3
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

4. Safety in Anesthesia
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• Safety in anesthesia is the highest priority
• Anesthesia is considered a high risk specialty compared to
other branches of medicine
• Theoretical high risk of morbidity and mortality and
considerable risk of adverse events
• Anesthesia is likened to aviation industry: no room for error
OVERVIEW
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5. Safety in Anesthesia
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DOCUMENTED ADVERSE EVENTS IN ANESTHESIA
▪ Cardiac arrest
▪ Perioperative MI
▪ Pulmonary aspiration
▪ Drug overdose/toxicity
▪ Anaphylaxis
▪ Convulsions
▪ Nerve palsies
▪ Organ injury: kidney, liver
▪ Failed airway/airway
obstruction
▪ Post-op nausea / vomiting, sore
throat
▪ Persistent sedation
▪ Hemodynamic instability
▪ Delirium
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6. Safety in Anesthesia
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TOP CAUSES OF CARDIAC ARREST UNDER ANETHESIA
• Drug overdose / adverse reaction
• Rhythm disturbances
• Perioperative MI
• Airway obstruction
• High/total spinal
• Lack of vigilance
• Bleeding
• Over-dosage of inhalation agent
• Aspiration
• Technical problem in anesthesia system
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7. Safety in Anesthesia
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ANETHESIA MORTALITY
• Anesthesia-related deaths have been drastically reduced over the years
• 1970’s: 1 death per 5,000 anesthetics administered
• 1999: 1 death per 200,000-300,000 anesthetics administered
• Modern day surgical patients are sicker, aged; high surgical burden
• Modern anesthesia is safer due to:
▪ Advanced monitoring equipment
▪ Safer drugs
▪ Advanced anesthetic machines
▪ Advanced airway management
▪ Improved anesthetic/surgical skills and knowledge
▪ Better guidelines and protocols
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

8. Safety in Anesthesia
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POTENTIAL CAUSES OF ADVERSE EVENTS IN ANETHESIA
• Lack of equipment or
essential supplies
• Poor supervision of
junior staff
• Organizational factors
HUMAN FACTORS PATIENT FACTORS SYSTEMS FACTORS
• Lack of vigilance
• Poor teamwork or
communication
• Lack of clinical
knowledge
• Poor technical
skills
• Co-morbidities (e.g.
severe illness)
• Emergency conditions
• Difficult airway
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9. Safety in Anesthesia
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A SAFE SYSTEM
• Preoperative Considerations
• Intraoperative Considerations
• Postoperative Considerations
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Safe
Surgery
Patient
Facilities,
Equipment,
Drugs
Anesthetist's
Skills
Surgeon's
Skills

10. Safety in Anesthesia
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ROUTINE PREOPERATIVE ASSESSMENT
Emergency or Elective:
• Patient risk factors
• Make an anesthetic plan
• Discuss/address any concerns
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

11. Safety in Anesthesia
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INTRAOPERATIVE CONSIDERATIONS
• Prepare/check all equipment
• Prepare and label all required drugs
• Assistance
• Avoid cluttered workspaces
• WHO surgical checklist
• Intraoperative monitoring
• Ongoing vigilance and communication
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12. 12
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

13. Safety in Anesthesia
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POSTOPERATIVE CONSIDERATIONS
• Awake + alert
• Airway clear
• Breathing well
• Circulation stable
• Temperature stable
• Pain controlled
• Wound not bleeding
• All lines flushed
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

14. Safety in Anesthesia
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• Be well-prepared
• Always do safety checks in theater
• Beware of similar-looking drugs, cluttered workspace
and distractions
• Always prioritize safety
• Be sure to do a thorough handover
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SUMMARY OF RECOMMENDATIONS

15. II. Patient Monitoring
15
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

16. Patient Monitoring
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• Continuous palpation of the radial pulsations
• Respiration depth and frequency
• Muscle movements
• Skin color
• Stages of excitation or sedation
HISTORY OF CLINICAL ASSESSMENT
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17. Patient Monitoring
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• Essential for ensuring patient safety
• Modern monitors have made anesthesia practice significantly
easier than before
• Both digital and clinical monitoring should be used for clinical
judgement
• Digital monitors should not replace provider’s clinical
assessment  clinical judgement is superior to monitor
output
GENERAL INFORMATION
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18. Patient Monitoring
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• To maintain the patient’s normal physiology and hemostasis
• To reduce and treat response to anesthesia and surgical stress
• To prevent and treat complications due to anesthetic drugs
• To prevent and treat intraoperative complications (hypothermia,
bleeding etc.)
WHY MONITOR DURING SURGERY?
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19. Patient Monitoring
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SMOOTH INDUCTION ADEQUATE MATINENCE
EMERENCY AND
RECOVERY
WHAT ARE WE AIMING FOR?
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20. Patient Monitoring
20
WHAT SHOULD YOU MONITOR IN A NORMAL CASE?
• Electrocardiogram (ECG)
• Saturation (SPO2)
• Blood Pressure (BP)
• End tidal carbon dioxide
(ETCO2)
• Temperature (T)
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21. Patient Monitoring
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ELECTROCARDIOGRAPHY
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22. Patient Monitoring
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WHAT DOES THE ECG TELL YOU?
Heart Rate
Normal Rhythm
Abnormal Rhythm
Ischemic Changes
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23. Patient Monitoring
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DANGER SIGNALS ON ECG
• Increase in T wave amplitude of more than 25%, suggesting
intravascular injection of local anesthetic drug with epinephrine
• Prominent T waves seen in hyperkaliemia, succinylcholine
injection, use of halothane in patients with muscular dystrophy
and after massive blood transfusion
• Prolonged QT interval in hypocalcaemia during rapid
transfusion of citrated blood and blood products
• Prolonged QT with T wave flattening in hypokalemia
• ST segment changes in cardiac ischemia
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24. Patient Monitoring
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ECG CONNECTION
3-Electrode System
Red  right
Yellow  left
Black  apex
*Able to read leads I, II, III
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

25. Patient Monitoring
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ECG CONNECTION
5-Electrode System
Red  right
Yellow  left
Black  under red
Green under yellow
White  central
*Able to read any of the 12 leads: I, II, III,
avR, avL, avF, V1-V6
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26. Patient Monitoring
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HOW TO ATTACH ECG ELECTRODES
• Choose a bony prominence
• Avoid fatty regions
• Avoid hairy areas (use jelly)
• Position them far away from eachother
• Ensure good contact with the skin
• If the electrodes will not be accessible during the surgery,
cover them after ensuring good ECG trace
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

27. Patient Monitoring
27
IF NO TRACE (NOISE)
• Follow ECG cable (patient to monitor)
• Ensure good contact with the patient
• Ensure proper fitting of cable connections
• Ensure proper fitting of the cable to the monitor
• Change monitor settings
• Ensure ’earthing’ of the monitor (earth cable from behind)
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

28. Patient Monitoring
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SPO2
SPO2 is the oxygen
content expressed as a
percentage of the oxygen
capacity
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

29. Patient Monitoring
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SPO2
• One of the most important indicators to monitor
• Should be continued through perioperative period
• Waveform of pulse oximeter = plethysmography
(arterial waveform)
• Indicates pulse oximeter is reading the arterial O2
saturation
• Without waveform pulse oximeter, readings are
unreliable and incorrect
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

30. Patient Monitoring
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WHAT DOES THE PULSE OXIMETER TELL YOU?
• SPO2
• Pulse rate vs heart rate
• Peripheral perfusion status (loss of waveform in hypotension
and in cold extremities)
• Irregularity of rhythm
• Cardiac arrest
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

31. Patient Monitoring
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ATTACHING THE PROBE
• Attached to finger, toe, or
ear lobe
• Red light is applied to nail
• Typically attached to the
limb with the IV line
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

32. Patient Monitoring
32
SPO2 READINGS
• Normal person on room air (O2 = 21%) ˃ 96%
• Patient under GA (100% O2) = 98-100%
• It is not acceptable for O2 saturation to decrease below 96%
with 100% O2 under GA.
Search and treat for possible causes of hypoxia
if SPO2 < 96%
This suggests hypoxemia
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

33. Patient Monitoring
33
POSSIBLE CAUSES OF ERRORS
• Slipped or misplaced on the patient’s finger
• Patient movement and shivering
• Poor tissue perfusion (vasoconstriction, cold extremities
etc.)
• Poor tissue perfusion (hypotension and shock)
• Cardiac arrest
• Electrical interference from cautery in some monitors
• Nail polish and stains (should be removed in advance)
• Bright ambient light
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

34. Patient Monitoring
34
• Keep the sound on at all times
• Pay attention to the sound of the pulse oximeter
• Hypoxia should be treated immediately
• Do clinical examination
• Clinical judgement is more important
• Call for help
DO NOT SILENCE MONITORS
OR
USE HEADPHONES
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

35. Patient Monitoring
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BLOOD PRESSURE MONITORING
• IBP
• NIBP
• Manual
• Automated
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

36. Patient Monitoring
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COMMON CAUSES OF ERRORS
• Disconnection of pressure line
• Leakage from damaged cuff
• Compressed line (under
someone’s foot or under a
weal)
• Incorrect cuff size: cuff cannot
inflate due to infant or neonate
limits
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

37. Patient Monitoring
37
CAPNOGRAPHY (End Tidal CO2)
Continuous CO2 measurement displayed as a waveform sampled
from the patient’s airway during ventilation
What is ETCO2?
A point on the capnograph. It is the final measurement at the
endpoint of the patient’s expiration before inspiration begins again.
It is usually the highest CO2 measurement during ventilation.
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring
NORMAL VALUES
• 30 – 43 mmHg
• 4.0 – 5.7 kPa
• 4.0 – 5.6%

38. Patient Monitoring
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FACTORS AFFECTING ETCO2
INCREASE DECREASE
• Increased muscular activity
• Increased cardiac output
• Effective treatment of
bronchospasm
• Hypoventilation
• Rebreathing
• Partial airway obstruction
• Laparoscopy (CO2
• Decreased muscular activity
• Decreased cardiac output
• Bronchospasm
• Hyperventilation
• Pulmonary emboli
• Hypothermia
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

39. Patient Monitoring
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TEMPERATURE MONITORING
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40. III. Hypothermia vs Hyperthermia
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UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

41. Hypothermia vs Hyperthermia
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UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

42. Hypothermia vs Hyperthermia
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UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring

43. Patient Monitoring
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• Cardiac arrhythmias; VT &
cardiac arrest
• Myocardial depression
• Delayed recovery (by
delaying drug metabolism)
• Delayed enzymatic drug
metabolism
• Metabolic acidosis
• Coagulopathy / bleeding
• Infection (SSI)
• Use of warm IV fluids
• Use of warming blanket
(esp. in pediatric anesthesia)
COMPLICATIONS
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PREVENTION / TREATMENT

44. Patient Monitoring
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HYPERTHERMIA (temp > 37.5 – 38.3 °C)
Malignant Hyperthermia (MH)
• Rare inherited disorder of skeletal muscle:
• 1 in 10,000 to 1 in 250,000 anesthetic exposures
• Hypermetabolic response triggered by:
• Halogenated anesthetics,
• Succinylcholine,
• Both
• Important to know the signs  can be rapidly
fatal
UAM Simulation-based Training I Lecture Content | Patient Safety & Monitoring