Monitoring in Anesthesia.ppt
Monitoring in AnesthesiaTopic modulev1.v2.v3.ContentsvIntroductionvWhat is monitoring?vWhich,Why and How to monitor?vLevel of monitoringvStandards for basic intraoperative monitoring(ASA)vSystematic monitoringvConclusionMonitoring:A Definitionv.interpret available clinical data to help recognize present or future mishaps or unfavorable system conditionsv.not restricted to anesthesia(change“clinical data”above to“system data”to apply to aircraft and nuclear power plants)What is monitoring?vto monere(,)vPhysiologic parameter&Patient safety parameter vClinical skills&Monitoring equipment vData collection,interpretation,evaluation,decisionvProblem seeking,Severity assessment,Therapeutic assessment,Evaluation of Anesthetic interventionsPatient Monitoring and Management Involves vThings you measure(physiological measurement,such as BP or HR)vThings you observe(e.g.observation of pupils)vPlanning to avoid trouble(e.g.planning induction of anesthesia or planning extubation)vInferring diagnoses(e.g.unilateral air entry may mean endobronchial intubation)vPlanning to get out of trouble(e.g.differential diagnosis and response algorithm formulation)Level of monitoringvRoutine/Specialize/ExtensivevNon-equipment/Non-invasive/Minimally invasive /Penetrating/Invasive/Highly invasivevSystematicvRespiratory/Cardiovascular/Temperature/FetalvNeurological/Neuro-muscular/Volume status&RenalvStandards for basic intraoperative monitoring (ASA)Standards for basic intraoperative monitoring(ASA:American Society of Anesthesiologists)Standard I vQualified anesthesia personnel shall be present in the room throughout the conduct of all GA,RA,MACStandard II vDuring all anesthetics,the patients respiratory(ventilation,oxygenation),circulation and temperature shall be continually evaluated Monitoring in the PastvVisual monitoring of respiration and overall clinical appearancevFinger on pulsevBlood pressure(sometimes)Monitoring in the PastFinger on the pulseHarvey Cushing Not just a famous neurosurgeon but the father of anesthesia monitoringvInvented and popularized the anesthetic chartvRecorded both BP and HRvEmphasized the relationship between vital signs and neurosurgical events(increased intracranial pressure leads to hypertension and bradycardia)Depth of Anesthesia MonitorEvoked Potential MonitorTransesophageal EchocardiographyCardiovascular monitoringvRoutine monitoringvCardiac activityvAdvanced monitoringvDirect arterial blood pressurevCardiac filling pressure monitorvCentral venous pressurevPulmonary capillary wedge pressureCardiovascular monitoringvElectrocardiographyvCardiac activityvArrhythmia:Lead IIvMyocardial ischemia:ECG criteriavElectrolyte imbalancevPacemaker functionCardiovascular monitoring 1.lead II,modified V5 2.-arrhythmia:bradycardia,tachycardia,AF,PVC,VT,VF-Myocardial ischemia-electrolyte imbalanceCardiovascular monitoringvNon-invasive blood pressure(NIBP)vCuff:width 120-150%limb diameter,air bladder includes more than halfway around limbvManometer:aneroid,mercuryvDetector:manual,automated Cardiovascular monitoringvNon-invasive blood pressurevInaccurate:cuff size,inflated pressure,shivering,cardiac arrhythmia,severe vasoconstrictionProper applicationNarrow cuffLoose cuffCardiovascular monitoringvDirect arterial pressure monitorv Indicationsv Continuous blood pressure monitor:anticipated cardiovascular instability,direct manipulation of cardiovascular system,inability to accurate measurement directlyv Frequent arterial blood sampling:ABG,Acid-base/electrolyte/glucose disturbance,CoagulopathiesCardiovascular monitoringvDirect arterial pressure monitorvContraindicationsvLocal infectionvImpaired blood circulation:Raynauds phenomenon,DMvRisks of thrombosis:hyperlipidemia,previous brachial artery cannulationvModified Allens test?()Cardiovascular monitoringvDirect arterial pressure monitorv Complicationsv Direct trauma:AV-fistula,Aneurysmv Hematomav Infectionsv Thrombosisv Embolizationv Massive blood lossCardiovascular monitoringvCardiac filling pressure monitorv Frank-Starling curve:optimum Preload maximize ventricular performance(Stroke volume,CO.)vPreload=Myocardial fiber length(2.2 micron)vLV Preload LVEDV LVEDP LAP PCWP PAP RVP RAP CVPvMyocardium function,LV compliance,Mitral valve,Airway pressure,Pulmonary vascular resistance,Pulmonic valve,Tricuspid valveCardiovascular monitoringvCardiac filling pressure monitorvLV Preload LVEDV LVEDP LAP PCWP PAP vLVEDP RVEDP RAP CVPCardiovascular monitoringvCardiac filling pressure monitorvPCWP:Pulmonary capillary wedge pressurevCVP:Central venous pressureCardiovascular monitoringvPCWP:Pulmonary capillary wedge pressurevCVP:Central venous pressure to optimize preload and maximize Cardiac performanceRespiratory monitoringvVentilatory monitoringvOxygenation monitoringvMachine and Circuit monitoringvClinical skillsvMonitoring devicesVentilatory monitoringvClinical skillsvDirect observation:rate,rhythm,volume of respirationvAuscultation:precordial,esophageal stethoscopevPalpation:reservo
