Monitoring In Anesthesia

1. Monitoring In Anesthesia Prof. Abdulhamid Al-Saeed, FFARCSI Anaesthesia Department College of Medicine King Saud University

2. Monitoring: A Definition • interpret available clinical data to help recognize present or future mishaps or unfavorable system conditions

3. Patient Monitoring & Management Involves … • Things you measure(physiological measurement, such as BP or HR) • Things you observe(e.g. observation of pupils) • Planning to avoid trouble(e.g. planning induction of anesthesia or planning extubation) • Inferring diagnoses(e.g. unilateral air entry may mean endobronchial intubation) • Planning to get out of trouble(e.g. differential diagnosis and response algorithm formulation)

4. Monitoring in the Past • Visual monitoring of respiration and overall clinical appearance • Finger on pulse • Blood pressure (sometimes) Finger on the pulse

5. Monitoring in the Present • Standardized basic monitoring requirements (guidelines) from the ASA (American Society of Anesthesiologists), CAS (Canadian Anesthesiologists’ Society) and other national societies • Many integrated monitors available • Many special purpose monitors available • Many problems with existing monitors (e.g., cost, complexity, reliability, artifacts)

6. ASA Monitoring Guidelines • STANDARD I Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care. http://www.asahq.org/publicationsAndServices/standards/02.pdf

7. ASA Monitoring Guidelines • STANDARD II During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated. http://www.asahq.org/publicationsAndServices/standards/02.pdf

8. CAS Monitoring Guidelines • The following are required: • Pulse oximeter • Apparatus to measure blood pressure, either directly or noninvasively • Electrocardiography • Capnography, when endotracheal tubes or laryngeal masks are inserted. • Agent-specific anesthetic gas monitor, when inhalation anesthetic agents are used.

9. CAS Monitoring Guidelines • The following shall be exclusively available for each patient: • Apparatus to measure temperature • Peripheral nerve stimulator, when neuromuscular blocking drugs are used • Stethoscope — either precordial, esophageal or paratracheal • Appropriate lighting to visualize an exposed portion of the patient.

10. High Tech Patient Monitoring Examples of Multiparameter Patient Monitors

11. High Tech Patient Monitoring Transesophageal Echocardiography Depth of Anesthesia Monitor Evoked Potential Monitor Some Specialized Patient Monitors

12. Pulse Oximetry

13. Physical Principle Within the probe are two light emitting diodes (LED's), one in the visible red spectrum (660nm) and the other in the infrared spectrum (940nm). The beams of light pass through the tissues to a photodetector. During passage through the tissues, some light is absorbed by blood and soft tissues depending on the concentration of haemoglobin. The amount of light absorption at each light frequency depends on the degree of oxygenation of haemoglobin within the tissues Microprocessor can select out the absorbance of the pulsatile fraction of blood Within the oximeter memory is a series of oxygen saturation values obtained from experiments performed in which human volunteers were given increasingly hypoxic mixtures of gases to breath. The microprocessor compares the ratio of absorption at the two light wavelengths measured with these stored values, and then displays the oxygen saturation digitally as a percentage and audibly as a tone of varying pitch. As it is unethical to desaturate human volunteers below 70%, it is vital to appreciate that oxygen saturation values below 70% obtained by pulse oximetry are unreliable.

14. A pulse oximeter gives NO information on any of these other variables: • The oxygen content of the blood • The amount of oxygen dissolved in the blood • The respiratory rate or tidal volume i.e. ventilation • The cardiac output or blood pressure

15. Incomptencies • Critically ill with poor peripheral circulation • Hypothermia & VC • Dyes ( Nail varnish ) • Lag Monitor Signalling 5-20 sec • PO2 • Cardiac arrhythmias may interfere with the oximeter picking up the pulsatile signal properly and with calculation of the pulse rate • Abnormal Hb ( Met., carboxy)

16. Capnography • Capnography is the graphic display of instantaneous CO2 concentration versus time (Time Capnogram) • Or expired volume (Volume Capnogram) during a respiratory cycle. • Methods to measure CO2 levels include infrared spectrography, Raman spectrography, mass spectrography, photoacoustic spectrography and chemical colorimetric analysis

17. Physical Principle • The infrared method is most widely used and most cost-effective. • Infrared rays are given off by all warm objects and are absorbed by non-elementary gases (i.e. those composed of dissimilar atoms), while certain gases absorb particular wavelengths producing absorption bands on the IR electromagnetic spectrum. • The intensity of IR radiation projected through a gas mixture containing CO2 is diminished by absorption; this allows the CO2 absorption band to be identified and is proportional to the amount of CO2 in the mixture.

18. Types Side stream Capnography • The CO2 sensor is located in the main unit itself (away from the airway) and a tiny pump aspirates gas samples from the patient’s airway through a 6 foot long capillary tube into the main unit. • The sampling tube is connected to a T-piece inserted at the endotracheal tube or anaesthesia mask connector Other advantages of the side stream capnograph • No problems with sterilisation, ease of connection and ease of use when patient is in unusual positions like the prone position

19. Main stream Capnograph • Cuvette containing the CO2 sensor is inserted between the breathing circuit and the endotracheal tube. • The IR rays traverse the respiratory gases to an IR detector within the cuvette. • To prevent condensation of water vapour, which can cause falsely high CO2 readings, all main stream sensors are heated above body temperature to about 40oC. • It is relatively heavy and must be supported to prevent endotracheal tube kinking. • Sensor’s window must be kept clean of mucus and particles to prevent false readings. • Response time is faster

20. The Alpha angle The angle between phases II and III, which has increases as the slope of phase III increases. The alpha angle is an indirect indication of V/Q status of the lung. Airway obstruction causes an increased slope and a larger angle. Other factors that affect the angle are the response time of the capnograph, sweep speed, and the respiratory cycle time. The Beta angle The nearly 90 degrees angle between phase III and the descending limb in a time capnogram has been termed as the beta angle. This can be used to assess the extent of rebreathing. During rebreathing, there is an increase in beta angle from the normal 90 degrees.

21. Clinical Applications

27. Monitoring NMJ DEPOLARISING BLOCK • Fasiculation • No tetanic fade • No post-tetanic potentiation • Anticholinesterases increase block • Potentiation by other depolarisers May develop Phase 2 block

28. NON-DEPOLARISING BLOCK • No fasiculation • Tetanic fade • Post-tetanic facilitation • Anticholinesterases decrease block • Antagonism by other depolarisers No change in character of block

30. Train of four (TO4) • Fade is prominent with non-depolarising blockers and at 0.5 Hz is greatest by the 6th twitch. Using four twitches at 0.5 second intervals (TO4) was popularised by Ali and from these the ratio of T4/T1 (the "TO4 Ratio") can be derived. The degree of paralysis is estimated from the number of twitches present, or if four are present the TO4 ratio. • Counting the number of palpable twitches is quite a good guide to deeper levels of paralysis; two or more twitches usually implies reasonably easy reversal and some return of muscle tone, while virtually no response suggests difficulty with reversal, weak cough at best, and very little muscle tone. • TO4 ratios around 0.25 are commonly estimated at between 0.1 and 0.7, while at 0.5 some 40% of and at 0.7 fewer than 10% of observers can reliably detect any fade at all. Consequently the presence of any detectable fade indicates the presence of some paralysis and furthermore even if all four twitches appear normal many patients are in fact partly paralysed. • It cannot be used to assess very deep levels of block (no T1!) and is not very sensitive to assessing adequacy of reversal.

31. Dual Burst Stimulation (DBS) • 50Hz train of 3 repeated 0.75 seconds later by an identical train of three. Each group of three twitches results in one twitch, and hence only two twitches available for comparison. Since the first twitch sums T1, T2 and T3, while the second sums T4, T5, and T6, it is easy to see how the presence of fade would be easier to notice and there is data to support this. As the level of block increases, response to the second burst is lost as the third twitch of TO4 is lost; the first burst is retained until a little after you lose all response to TO4. Surgical paralysis is generally OK if only one response is present; the patient is reversible if two are present, particularly if the second is strong. TO4 is better for quantifying the intensity of "surgical" paralysis, whereas DBS is better for noting persistance of fade after reversal. If you use NMB's so that there is just no response to DBS, the patient will be a little more paralysed than if there was just no response to TO4.

32. Tetanic stimulation • Continuous stimulation at either 50 or 100 Hz is so painful as to preclude its use in conscious patients, and is difficult to quantify, but is probably the most useful and emulates physiological maximal responses. Tetany is more sensitive to both residual and deep paralysis than any other form of monitoring. The presence of any persisting strength during tetany is a good indicator of the patient's ability to maintain muscle tone. • Comparing two bursts of tetany (each 3-5 seconds long) with a gap of 3 seconds results in post-tetanic potentiation of the response to the second burst. When assessing adequacy of reversal the initial part of the second response (potentiated) can be compared to the last part of the first (faded). • If fade is present it is becomes more obvious with this rather than any other method.

33. Post-Tetanic Count (PTC) • This consists of counting 1 Hz twitches 3 seconds after 5 seconds of 50Hz tetany and can give an approximate time to return of response to single twitches and hence permits assessment of block too deep for any other technique. A Post-Tetanic Count (PTC) of 2 by palpation suggests no twitch response for about 20-30 minutes, PTC of 5 about 10-15 minutes. • This is clearly the best method for monitoring paralysis for patients in whom you seek to prevent diaphragmatic movement, ie micro-neurosurgery; it is best to use infusions of drugs and aim for PTC of 2.

34. Arterial Blood Pressure

36. Damping is the tendency of the system to resist oscillations caused by sudden changes • Overdamping The waves tend to faltten thus underestimating systolic reading and Overestimating diastolic reading • Underdamping magnify the waves with overshooting, thus overestimating systolic reading and uinderestimating diastolic reading

37. Factors causing Overdamping 1- Narrow tubing 2- Long elastic tubings(Compliant ) 3- High density fluid 4- Air bubbles 5- Clot formation

38. Central Venous Pressure

41. PULMONARY ARTERY CATHETER

42. Pulmonary Artery Catheter

44. Haemodynamic Profiles Obtained from PA Catheters • SV = CO / HR (60-90 mL/beat) • SVR = [(MAP – CVP) / CO]  80 (900-1500 dynes-sec/cm5) • PVR = [(MPAP – PCWP) / CO]  80 (50-150 dynes-sec/cm5)

45. O2 delivery (DO2) • = C.O.  O2 content • Arterial O2 content (CaO2)= ( Hb  1.38 )  (SaO2) • Mixed venous O2 content (CvO2)= ( Hb  1.38 )  (SvO2) • O2 consumption (VO2)= C.O.  (CaO2-CvO2) • SvO2 = SaO2– [VO2 / (Hb  13.8)(CO)]

46. ECG

47. Electrocardiogram • Displays the overall electrical activities of the myocardial cells • Heart rate & dysrhythmias • Myocardial ischaemia • Pacemaker function • Electrolyte abnormalities • Drug toxicity • Does NOT indicate mechanical performance of the heart: • Cardiac output • Tissue perfusion

48. Full (12)-lead ECG • Standard limb leads (bipolar) • Precordial leads (unipolar) 5-lead system • Unipolar + bipolar • RA, LA, RL, LL, C 3- lead system Bipolar with RA, LA, LL V5 usually used • Best compromise between detecting ischaemia and diagnosing arrhythmia May come with ST-segment analysis

49. ECG Standard Limb Leads Unipolar Chest Leads