The document discusses various parameters that are monitored during physiologic monitoring, including hemodynamic monitoring (arterial and central venous catheterization), respiratory monitoring (ventilation and gas exchange), renal monitoring (urine output and glomerular function tests), and neurologic and metabolic monitoring. Key details provided include normal values, indications for monitoring, techniques, and potential complications.

1. PHYSIOLOGIC MONITORING CELSO M. FIDEL, MD, FPCS, FPSGS Diplomate Philippine Board of Surgery

3. Parameters Monitored Hemodynamic Monitoring RESPIRATORY Monitoring Renal Monitoring Neurologic monitoring Metabolic monitoring temperature monitoring

4. Hemodynamic Monitoring 1. Provides information as to the C-P status of the patient 2. Traditional clinical assessment are usually unreliable 3. Major changes in the cardiovascular status may not be clinically obvious 4. Invasive techniques must be utilized

5. Hemodynamic Monitoring A. Arterial Catheterization 1. Indications a. Need for continuous blood pressure monitoring. b. Need for frequent arterial blood sampling.

6. Hemodynamic Monitoring Conditions that need continuous and accurate BP monitoring: i. Shock states ii. Hypertensive crisis iii. Surgery in high risk patients iv. Use of potent vasoactive or inotropic drugs v. Controlled hypotensive anesthesia vi. Situations that may lead to rapid changes in cardiac function Arterial Catheterization

7. Hemodynamic Monitoring 2. contraindications No ABSOLUTE contraindication to arterial catheterization RELATIVE contraindications are: a. Bleeding problems (hemophilia) b. Anticoagulant therapy c. Presence of a vascular prosthesis d. Local infection Arterial Catheterization

8. Hemodynamic Monitoring 3. Sites of catheterization a . R adial artery b. Axillary artery c. Femoral artery d. Dorsalis pedis artery e. Superficial femoral artery f. Brachial artery Arterial Catheterization

9. Hemodynamic Monitoring 3. Sites of Catheterization a. radial artery - dual blood supply - most commonly used site - simple canulation - low complication rate - modified “Allen’s” test – assess ulnar artery - Doppler technique, plethysmography, pulse oximetry

10. Hemodynamic Monitoring 3. Sites of Catheterization b. axillary artery - for long term monitoring - large size - close proximity to the aorta - deep location - technical difficulty in insertion - located near neurovascular structures

11. Hemodynamic Monitoring 3. Sites of Catheterization c. femoral artery - large size and superficial location - prone to atherosclerosis - difficult to keep clean

12. Hemodynamic Monitoring 3. Sites of Catheterization d. dorsalis pedis e. superficial temporal artery - surgical exposure is required - neurologic complications observed

13. Hemodynamic Monitoring 3. Sites of Catheterization f. brachial artery - for short term use only - median nerve contracture (Volkman’s contracture)

14. Hemodynamic Monitoring Arterial Catheterization 4. Complications of arterial catheterization a. failure to cannulate b. hematoma c. disconnection from monitoring system

15. Hemodynamic Monitoring Arterial Catheterization 4. Complications of arterial catheterization d. infection - catheters in place for more than 4 days - surgical insertion - local inflammation e. retrograde cerebral embolization f. A-V fistula / pseudoaneurysm g. severe pain, distal necrosis

16. Hemodynamic Monitoring B. Central Venous Catheterization 1. Indications a. access for fluid therapy b. access for drug infusion c. parenteral nutrition d. CVP monitoring

17. Hemodynamic Monitoring B. Central Venous Catheterization 1. Indications e. other indications - aspirate air embolism - placement of cardiac pacemaker / vena cava filters - hemodialysis access

19. Hemodynamic Monitoring B. Central Venous Catheterization 1 . Useful in hypotensive patients 2. Tracings for arrythmias 3. Gives information about the relationship between intravascular volume and right ventricular function 4. Use of a water manometer for pressure measurements 5. Normal CVP measurement 4-7 mmH2O

20. Central Venous Pressure Monitoring  In seriously ill patients the vital problem is determination of the proper amount of fluids and blood requirements necessary to MAINTAIN an optimal blood volume in the:  Preoperative  Operative  Postoperative Hemodynamic Monitoring

21. Hemodynamic Monitoring Central Venous Pressure Monitoring  CVP Monitoring is a reliable procedure to evaluate properly and promptly optimal fluid and blood requirement in these patients .  The procedure removes much of the guess work in rapid restoration and maintenance of adequate circulation w/o fear of overloading the heart

22. Hemodynamic Monitoring Central Venous Pressure Monitoring 2. Sites of catheterization a. subclavian vein - easiest to cannulate - pneumothorax most common complication - difficult to control bleeding

23. Hemodynamic Monitoring Central Venous Pressure Monitoring 2. Sites of catheterization b. internal jugular vein - lower risk of pneumothorax - arterial puncture most common complication c. external jugular vein d. basilic vein

24. Hemodynamic Monitoring Central Venous Pressure Monitoring ( .  CVP measured anywhere in the SVC or IVC or their immediate tributaries>>>Innominate, and the Common Iliac Veins  It is determined by a complex interaction of:  Blood Volume  Cardiac Pump Action  Vascular Tone  Serves as index of circulating blood volume relative to the Cardiac Pump Action

25. Hemodynamic Monitoring Central Venous Pressure Monitoring (  CVP or the pressure in the Right Atrium & adjacent Caval system will reflect ability of the Cardiac Pump Action to handle the returning blood volume at that particular time.  Indications:  When Massive blood replacement is instituted rapidly in rapid exsanguinating type of bleeding.

26. Hemodynamic Monitoring Central Venous Pressure Monitoring (  Indications:  In Acute blood volume deficit in cases operated for strangulating type of Intestinal Obstruction where rapid fluid replacement is indicated  In obscure cases of Shock immediately post- op whether hypovolemic due to internal bleeding or nonhypovolemic from Myocardial Infarction.

27. Hemodynamic Monitoring Central Venous Pressure Monitoring (  Indications:  In elderly patients with limited cardiac reserve undergoing difficult, time consuming operations.  In surgical patients with anuria due to possible renal shutdown.

28. Hemodynamic Monitoring Central Venous Pressure Monitoring Basic Facts about CVP .  Normal CVP is about 4 to 7 cm  Low CVP 0-3 circulating blood vol. is below the normal blood volume the heart can handle.  High CVP 8-20 (more than the heart can handle)

29. Hemodynamic Monitoring Central Venous Pressure Monitoring  Technique  Cannulation of the Superior Vena Cava through Basilic or Cephalic Veins.  A polyethelene tube size French 8 and 42 inches long is inserted at the Basilic Vein just above the elbow and pushed up to 20 inches.

30. Hemodynamic Monitoring Central Venous Pressure Monitoring  Technique  Connect an Intravenous administration set to the venous catheter through which IV fluid, may be administered.  A Manometer is connected to IV set w/ a three way stopcock. Zero point should be at level of the Atrium or approximately at Mid-axillary line

31. Hemodynamic Monitoring Central Venous Pressure Monitoring Complications 1. catheter malposition 2. dysrythmmias 3. embolization 4. vascular injury 5. cardiac, pleural, mediastinal, neurologic injury

32. Respiratory Monitoring Monitoring ventilation and gas exchange * Indications 1. Decision making for the need of mechanical ventilation. 2. Assessment of response to therapy. 3. Optimize ventilatory management. 4. Decision to wean from ventilator.

33. Respiratory Monitoring Monitoring ventilation and gas exchange A. Ventilation monitoring 1. Tidal volume – volume of air moved in or out of the lung in a single breath 2. Vital capacity – maximal volume at expiration after a maximal inspiration 3. Minute volume – total volume of air leaving the lung each minute 4. Phsiologic dead space – the portion of tidal volume that does not participate in in gas exchange a. anatomic dead space b. phsiologic dead space

34. Respiratory Monitoring Monitoring ventilation and gas exchange A. Ventilation monitoring 4. Phsiologic dead space – the portion of tidal volume that does not participate in in gas exchange a. anatomic dead space b. phsiologic dead space

35. Respiratory Monitoring Monitoring ventilation and gas exchange B. Gas Monitoring - Reported as directly measured partial pressures (PO2 and PCO2) - Use of pulse oximeters for continuous measurements 1. Blood gas analysis – information about: a. efficacy of gas exchange b. adequacy of alveolar ventilation c. acid – base status

36. Respiratory Monitoring Monitoring ventilation and gas exchange B. Gas Monitoring 2. Capnography - graphic display of CO2 concentration in wave form - available systems a. infrared analysis b. mass spectrometry c. Raman scattering d. disposable colorimetric devices e. semi-quantitive measurement on the end- tidal CO2 concentration

37. Respiratory Monitoring B. Gas Monitoring 3 . Pulse oximetry reliable, real time estimation of the arterial Hgb saturation - wide clinical acceptance

39. Respiratory Monitoring Monitoring ventilation and gas exchange B. Gas Monitoring 4. Gastric Tonometry - relatvely non-invasive monitoring of adequacy of aerobic metabolism in organs whose superficial mucosal lining is extremely vulnerable to low flow changes and hypoxemia

40. Renal Monitoring The kidney is an excellent monitor of adequacy of perfusion Prevention of renal failure Predict drug clearance and proper dose adjustment

41. Renal Monitoring A. Urine Output - Commonly monitored but may be misleading - Normal urine output  0.5 ml/kg/hour - Correlates with glomerular filtration rate (GFR) - High output may not accurately reflect GFR ex. Diabetes Insipidus - May be affected by other factors

42. Renal Monitoring B. Glomerular Function Tests 1. Blood Urea Nitrogen (BUN) a. Affected by GFR and urea production b. Increased in TPN, GI bleeding, trauma, sepsis, steroid use c. Lowered in starvation, liver disease d. Not a reliable test

43. Renal Monitoring 2. Plasma Creatinine a. More accurate than BUN b. Directly proportional to creatinine production c. Inversely related to GFR d. Not affected by protein or nitrogen production or rate of fluid flow through tubules e. Related to muscle mass

44. Renal Monitoring 3. Creatinine Clearance a. used if values of plasma creatinine are affected by muscle disease b. serial determination of urine is done and is currently the most reliable method of assessing GFR

45. Renal Monitoring C. Tubular Function Tests 1. The most reliable test to distinguish pre- renal azotemia from tubular necrosis 2. Requires simultaneous collected urine and blood samples

46. Neurologic Monitoring Early recognition of cerebral dysfunction Facilitate prompt intervention and treatment

47. Neurologic Monitoring A. Intracranial Pressure Monitoring 1. Cerebral Perfusion Pressure - >70mmHg 2. Glasgow Coma Scale

48. Neurologic Monitoring B. Electrophysiologic Monitoring Reflects spontaneous and on- going electrical activity in the brain

49. Neurologic Monitoring C. Trans-cranial Ultrasound Monitors cerebral blood flow Detects vasospasm

50. Neurologic Monitoring D. Jugular Venous Oximetry Measures relationship of blood flow to O2 consumption

51. Metabolic Monitoring A. Caloric Demands B. Respiratory Quotient of Food

52. Temperature Monitoring A. Rectal B. Middle Ear C. Esophageal

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