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Physiologic Monitoring of the Surgical Patient

Physiologic Monitoring of the Surgical Patient . Basic Science Conference 1/26/2010. Background. Latin word monere , which means “to warn, or advise,” is the origin for the English word monitor.

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Physiologic Monitoring of the Surgical Patient

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  1. Physiologic Monitoring of the Surgical Patient Basic Science Conference 1/26/2010

  2. Background • Latin word monere, which means “to warn, or advise,” is the origin for the English word monitor. • Patients undergo monitoring to detect pathologic variations in physiologic parameters, in order to give us advance warning of deterioration of one or more organ systems. • GOAL: Use the information to make a timely intervention. • Monitoring also used to guide resuscitation and titrate medications.

  3. Background (cont.) • The ultimate goal of hemodynamic monitoring is to ensure that the flow of oxygenated blood through the microcirculation is sufficient to support aerobic metabolism at the cellular level. • This involves multiple inputs. • Oxygen delivery • CO • Hgb • O2 sat • PAO2

  4. Arterial Blood Pressure • The pressure exerted by blood in the systemic arterial system. • Hypotension = Shock ? • MAP = CO x SVR • How do we measure blood pressure? • Non-invasive (cuff) • Invasive • Risks and benefits

  5. Noninvasive • Manual and automated means, both of which use a cuff. The width of the cuff should be about 40% of the circumference. • Korotkoff sounds • Systolic- tapping sounds first audible • Diastolic- audible pulsations disappear • Dyna-map

  6. Invasive • Fluid-filled tubing to connect an intra-arterial catheter to external strain-gauge transducer which is transduced as a continuous waveform. • Underdamped –systolic overestimated and diastolic underestimated • Overdamped- systolic underestimated and diastolic overestimated • Use Mean Arterial Pressure • Systolic pressure higher, diastolic pressure lower in the radial artery compared to the aorta

  7. Invasive Complications • Thrombosis (Allen test) • Air Embolism • Infection

  8. EKG monitoring • Continuous monitoring with three lead EKG • Immediate alarm with arrhythmias • Can detect ST elevation • No substitute for 12 lead EKG

  9. Cardiac output • Determinants of Cardiac Performance • Preload - EDV • Afterload-SVR • Contractility- dependent on preload and afterload

  10. Pulmonary artery catheter • PAC has four channels • Balloon (1.5cc) • CVP, PA • Insertion • Waveforms • Distance • 45 cm RSCV • 50cm RIJ • 55cm LSC • 60cm LIJ

  11. Approximate Normal Ranges for Selected Hemodynamic Parameters in Adults • CVP 0–6 mmHg • Right ventricular systolic pressure 20–30 mmHg • Right ventricular diastolic pressure 0–6 mmHg • PAOP 6–12 mmHg • Systolic arterial pressure 100–130 mmHg • Diastolic arterial pressure 60–90 mmHg • MAP 75–100 mmHg • QT   4–6 L/min • QT*  2.5–3.5 L·min–1·m–2 • SV 40–80 mL • SVR 800–1400 dyne·sec·cm–5 • SVRI 1500–2400 dyne·sec·cm–5·m–2 • PVR 100–150 dyne·sec·cm–5 • PVRI 200–400 dyne·sec·cm–5·m–2

  12. Hemodynamic measurements • Cardiac output by thermodilution • Mixed venous oximetry • RV ejection fraction

  13. Types of Shock • Hemorrhagic • Septic • Cardiogenic • Neurogenic • Hypo adrenal

  14. Risks and benefits of PACs • Many studies show no mortality difference with PAC use and more complications related to the catheter or its placement. • Alternatives • Doppler Ultrasonography • Impedance cardiography • Pulse contour analysis • TEE

  15. Respiratory monitoring • The ability to monitor various parameters of respiratory function is of utmost importance is critically ill patients. • Arterial blood gases • Peak and plateau airway pressure • Pulse oximetry • CO2 monitoring

  16. ABG • O2 (PEEP, FIO2) • CO2 (RR, TV) • O2 sat • HCO3 • BE/BD

  17. Airway Pressures • Increased pressure = decreased compliance • Hemo/pneumothorax • Atelectasis • Pulmonary edema • ARDS • Abdominal distension • Barotrauma

  18. Renal monitoring • Urine output • Bladder pressure

  19. Neurologic monitoring • Intracranial pressure • CPP= MAP- ICP • CPP>60 • Allows monitoring and drainage • Strategies to decrease ICP • Transcranial doppler ultrasonography • EEG • Brain tissue oxygen tension

  20. Conclusions • Physiologic monitoring provides us with a multitude of information. • Determining what information is beneficial and using this to positively affect the outcome of the patient is the key.

  21. All of the following are most often associated with a decrease in SVO2 except: • Myocardial infarction • Cardiac tamponade • Hemorrhagic shock • Septic shock

  22. You place a swan ganz catheter in a 709kg adult male through the left subclavian vein and get a wedge pressure. The approximate distance into the patient should be: • 45cm • 50cm • 55cm • 60cm

  23. While trying to treat a patient with severe ARDS, you start to increase the PEEP to improve oxygenation. After doing this, you notice a decrease in urine output. The mechanism of decreased urine output with increased PEEP is: • Compartment syndrome • Decreased cardiac output • Reduced oxygenation • Retained CO2

  24. A patient stops making urine after surgery. All of te following values are consistent with pre-renal renal failure except: • Urine Na 5 • BUN/Cr ratio >35 • FeNA=0.1% • Urine osmolality 200 mOsm

  25. All of the following concerning pulmonary artery catheters are true except: • Excessive PEEP can artificially increase wedge pressure. • Excessive PEEP can artificially decrease wedge pressure. • Zone III of the lung is the optimal site of placement. • The balloon should be inflated when advancing the catheter.

  26. A critical care patient has the following PAC values: CI 1.8, SVR 3000, and a wedge pressure of 5. This is most consistent with: • Septic shock • Hypovolemic shock • Cardiogenic shock • Neurogenic shock

  27. A critical care patient has the following PAC values: CI 5.0, SVR 500, and a wedge pressure of 7. This is most consistent with: • Septic shock • Hypovolemic shock • Cardiogenic shock • Neurogenic shock

  28. A critical care patient has the following PAC values: CI 1.8, SVR 3000, and a wedge pressure of 28. This is most consistent with: • Septic shock • Hypovolemic shock • Cardiogenic shock • Neurogenic shock

  29. A critical care patient has the following PAC values: CI 2.0, SVR 500, and a wedge pressure of 5. This is most consistent with: • Septic shock • Hypovolemic shock • Cardiogenic shock • Neurogenic shock

  30. A patient with ARDS following an inhalation injury has an oxygenation saturation of 90% on 90% FiO2 with an SVO2 of 55. The patient’s ABG is pH 7.35, pO2 of 60, and pCO2 60. The patient has a cardiac output of 5, and a Hgb of 8. Oxygen delivery will increase the most by: • Increasing cardiac output by 1 • Increasing hemoglobin by 2 • Increasing FiO2 by 10% • Decreasing CO2 by 10% • Oxygen delivery = CO x[(Hgb x1.34x O2 sat) + (0.003x PaO2)]

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