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20 patient monitoring
The document discusses various methods of patient monitoring during anesthesia, including their purposes, advantages, and limitations. It covers monitoring vital signs, standards for basic anesthesia monitoring according to the ASA, techniques like non-invasive blood pressure monitoring, ECG, pulse oximetry, capnography, and invasive arterial line monitoring. Key aspects emphasized are integrating multiple monitoring methods to evaluate oxygenation, ventilation, and circulation.
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20 patient monitoring
- 1. Patient Monitoring 23November 2008 Elvin Cruz, MD, MS Med ETT Anesthesiologist Roizen: Essence of Anesthesia Practice Stoelting, Miller: Basics of Anesthesia Morgan, Mikhail: Anesthesiology Faust: Anesthesiology Review
- 2. Monitoring Why monitorvital signs? ASA standard of care on monitoring under anesthesia NIBP ECG Pulse oximetry Capnography Arterial blood pressure
- 3. Monitoring Data collectionEarly warning of adverse changes or trends Response to therapeutic interventions Reflect proper functioning of other equipment The most important monitor is YOU, the care provider Remain vigilant, integrate monitor information into patient care
- 4. ASA Standards forBasic Anesthesia Monitoring Applies to ALL anesthetics (GA, MAC, Regional) Intended to encourage quality patient care Can be exceeded at any time based on judgment Not intended for OB/pain management
- 5. STANDARD I Qualifiedanesthesia personnel continuously present STANDARD II: Continually evaluate Oxygenation Inspired gas: O 2 analyzer with low O 2 alarm* Blood oxygenation: POx, color assessment* Ventilation Chest excursion, Reservoir breathing bag observation, auscultation Quantitative ETCO 2 Expired volume quantification* ETT/LMA position verified with clinical assessment + ETCO 2 Disconnect alarm when using PPV ASA Standards for Basic Anesthesia Monitoring Can be waived under extenuating circumstances, document in the medical record record the reason
- 6. ASA Standards forBasic Anesthesia Monitoring Cont. STANDARD II: Continually evaluate Circulation Continuous ECG* NIBP & HR at least every 5 minutes* With GA: At least one of these Palpation of pulse Heart sounds auscultation IABP POx US peripheral pulse monitor Temperature Monitor when clinically significant changes anticipated/expected Can be waived under extenuating circumstances, document in the medical record record the reason
- 7. Automated oscillometric NIBPmonitor Non-invasive, automated Air pump with deflation valve to control cuff pressure Transducer measures cuff pressure and pressure oscillations within the cuff Systolic and MAP correlate well with invasive BP measurements, but diastolic usually 10 mmHg higher with this method
- 8. Automated oscillometric NIBPmonitor From: http://egems.gehealthcare.com/geCommunity/monitor/faq_bedside/nbp_faq.jsp Threshold
- 9. Size of cuffinfluences measurement of BP Too small a cuff => Falsely increased BP Too large a cuff => Falsely decreased BP Loosely wrapped cuff => Falsely increased BP Too frequent measurement or wrapped too tight => distal edema To avoid nerve damage Avoid applying cuff on bony prominences Avoid applying cuff across joints Select maximum cycle time consistent with safe monitoring Record cuff location and cycle time Keep ALARMS enabled Automated NIBP monitor complications
- 10. ECG Continuous visualdisplay Monitors cardiac electrical activities only, it does not measure heart function Early detection of Dysrhythmias: Lead II Myocardial ischemia: Lead V5 Electrolyte changes Allow calculation of HR
- 11. ECG Normal values(adults) : 60 < Pulse < 100 PR interval 0.12 – 0.20 sec QRS duration 0.06 – 0.10 sec QT interval <= 0.40 sec Pulse >100: Tachycardia Pulse <60: Bradycardia R-R interval
- 12. Normal Sinus rhythmHR ~ 85 bpm Pulse Rate estimation HR = 1500/#small boxes in R-R interval HR = 300/#large boxes in R-R interval
- 13. Sinus Tachycardia, HR ~ 135 Sinus Bradycardia, HR ~ 52
- 14. Monophasic VT (VentricularTachycardia), HR ~ 185 VFib (Ventricular Fibrillation)
- 15. Asystole Check pulseCheck connections Verify other leads Multifocal PVCs (Premature Ventricular Contractions)
- 16. Pulse Oximetry Practical,non-invasive, reliable monitoring of SpO 2 as a reflection of SaO 2 Early warning of arterial hypoxemia the need for PaO 2 determinations (ABGs) LED measures absorption of specific wavelengths of light during arterial pulsations Computer calculates SpO 2 SpO 2 > 90% correlates with PaO 2 > 60 mmHg Alarms for HR, SpO 2 values Acceptable in most cases: 92 <= SpO 2 <= 100 O 2 supplementation likely needed for SpO 2 < 93
- 17. Pulse oximetry OxygenatedHgb (HbO 2 ) and deoxygenatred Hgb (Hb) have different optical spectra in the 500-1000 nm wavelength range
- 18. Pulse oximetry Howto use: Prefer site without arterial catheter, BP cuff, or IV line Align light source and photodetector Move site of reusable sensor every 4 hours Check adhesive sensor site for skin integrity every 8 hours Reusable sensors thoroughly cleaned between patients Advantages Continuous monitor Non-invasive Early warning of arterial hypoxemia Monitor pulse rate Decreased need for SaO2 determinations (blood gas)
- 19. Pulse Oximetry LimitationsDecreased vascular pulsations (Low perfusion states) Hypotension Hypothermia Vasoconstriction Motion artifacts Shivering Agitated Light interference Ambient light Radiant warmers Nail polish (especially blue, green, brown)
- 20. Pulse Oximetry LimitationsDysfunctional hemoglobins can be interpreted as Oxyhemoglobin by the pulse oximeter COHgb interpreted as HbO 2 => Falsely high SpO 2 MethHgb biases SpO 2 reading towards 85% FetalHgb has little influence in SpO 2 Errors in data interpretation Skin burns in MRI TR results in venous pulsations => Falsely low SpO2, specially with ear probes
- 21. Pulse Oximetry LimitationsValues accurate from 70-100%. Any number below 70% is an extrapolation and not very accurate (although less than 70%). SpO 2 number likely to be inaccurate
- 22. Capnography Continuous measurementof patient’s inhaled and exhaled [CO 2 ] Waveform display more informative than the value Useful for evaluation of Esophageal intubation Disconnect in breathing circuit Rebreathing of CO 2 Cardiac arrest Malignant Hyperthermia / Thyroid storm Hypotension PE ETCO 2 underestimates PaCO 2 due to deadspace ventilation
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- 30. Invasive BP orArterial Line Monitoring Invasive, continuous measurement of arterial BP Catheter in a peripheral artery connected to a transducer and display Indications: Expected hemodynamic instability Rigorous control of blood pressure is necessary Need for analysis of multiple blood gas samples Not indicated for drug administration
- 31. Arterial Line MonitoringTechnique: Sterile prep, gloves Feel pulse 20G catheter for radial artery in adults, 22G in pediatrics Secure with suture and/or clear tape or dressing Transducer line with pressure tubing attached to IV fluids on a pressure bag set at 250 mmHg. Transducer setup infuses a few ml of saline into artery every hour to prevent clotting. Non-pressure tubing will dampen signal. Transducer is zeroed and positioned at the level of the heart Possible complications: Distal ischemia Infection Hemorrhage Any air in the line will dampen the signal
- 32. Arterial Line MonitoringCannulation site: Radial artery – most common site Femoral artery Dorsalis pedis Brachial artery Ulnar artery Axillary artery Site of placement of arterial line catheter determines the shape of the arterial pressure wave. The farthest from the heart, the higher the systolic pressure and the lower the diastolic pressure. MAP remains about the same at all sites Upon removal of arterial catheter hold pressure at insertion site for 3-5 minutes to prevent bleeding/hematoma