Intraoperative patient monitoring

A patient undergoing surgery under anesthesia is usually

experiencing a number of disturbances with regard to the normal
functioning of several body systems. This means that the
patient’s physiological status needs to be monitored at all times.
The types of monitoring required vary with the procedure being
undertaken.
The equipment used to monitor a patient throughout a surgical
operation is usually made up of one single system that can be set
to accurately and continuously measure a set of patient
parameters that reflect the functioning of the body systems.
Various sensors and electrodes are attached to the patient to
gather information. These measurements are displayed on
monitors.
Routinely measured parameters
The parameters measured in most surgical procedures include:
 The heart’s electrical activity via an electrocardiogram
 The respiratory rate

 The blood pressure, which can be measured by both

invasive and non-invasive means
 The body temperature via temperature probes or
thermometers, especially when general anesthesia lasts
over 30 minutes in duration.
 The cardiac output
 The arterial blood oxygen level measured by a pulse
oximeter, a photoelectric sensor clipped over the finger or
toe.
 Mixed venous oxygenation
 Pulmonary functions such as end-tidal carbon dioxide
 Intracranial pressure monitors in patients suffering from
trauma to the head, or raised intracranial pressure because
of brain tumors, edema, or intracranial hemorrhage. The

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 sensor is inserted through a burr hole made in the skull.
These are important in detecting rises in the pressure
inside the head, and recording the pattern for comparison.

Electrocardiography ECG

The ECG may be used in two ways.

A 12 lead ECG may be performed which analyses the cardiac

electrical activity from a number of electrodes positioned on the
limbs and across the chest. A wide range of abnormalities may
be detected including arrhythmias, myocardial ischemia, left
ventricular hypertrophy and pericarditis.

During anesthesia, however, the ECG is monitored using only 3

(or occasionally 5) electrodes which provide a more restricted
analysis of the cardiac electrical activity and cannot provide the
same amount of information that may be revealed by the 12 lead
ECG. The term ‘lead’ when applied to the ECG does not
describe the electrical cables connected to the electrodes on the
patient. Instead, it refers to the positioning of the 2 electrodes
being used to detect the electrical activity of the heart. A third
electrode acts as a neutral.

During anesthesia one of 3 possible ‘leads’ is generally used.

These leads are called bipolar leads as they measure the
potential difference (electrical difference) between two
electrodes. Electrical activity travelling towards an electrode is
displayed as a positive (upward) deflection on the screen, and
electrical activity travelling away as a negative (downward)
deflection. The leads are described by convention as follows:

Lead I: measures the potential difference between the right

arm electrode and the left arm electrode. The third electrode (left
leg) acts as neutral.

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Lead II: measures the potential difference between the right
arm and left leg electrode.

Lead III: measures the potential difference between the left arm
and left leg electrode. Most monitors can only show one lead at
a time and therefore the lead that gives as much information as
possible should be chosen.

The most commonly used lead is lead II (figure 5) - a bipolar

lead with electrodes on the right arm and left leg as above. This
is the most useful lead for detecting cardiac arrhythmias as it
lies close to the cardiac axis (the overall direction of electrical
movement) and allows the best view of P and R waves.

For detection of myocardial ischemia, the CM5 lead is useful

(figure 6). This is a bipolar lead with the right arm electrode
placed on the manubrium and left arm electrode placed at the
surface marking of the V5 position (just above the 5th interspace
in the anterior axillary line). The left leg lead acts as a neutral
and may be placed anywhere- the C refers to ‘clavicle’ where it
is often placed. To select the CM5 lead on the monitor, turn the
selector dial to ‘lead I’. This position allows detection of up to
80% of left ventricular episodes of ischemia, and as it also
displays arrhythmias it can be recommended for use in most
patients. The CB5 lead is another bipolar lead which has one
electrode positioned at V5 and the other over the right scapula.
This results in improved QRS and P wave voltages allowing
easier detection of arrhythmias and ischemia. Many other
electrode positions have been described including some used
during cardiac surgery, for example esophageal and intracardiac
ECG’s.

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CARDIAC ARRHYTHMIAS

The detection of cardiac arrhythmias and the determination of

heart rate is the most useful function of the intraoperative ECG.

Anesthesia and surgery may cause any type of arrhythmia

including: Transient supraventricular and ventricular
tachycardias due to sympathetic stimulation during
laryngoscopy and intubation. Bradycardias produced by
surgical manipulation resulting in vagal stimulation. Severe
bradycardia and asystole may result. It is more common in
children because the sympathetic innervation of the heart is
immature and vagal tone predominates. Bradycardias are most
commonly seen in ophthalmic surgery due to the oculocardiac
reflex. Generally, the heart rate will improve when the surgical
stimulus is removed. Atrial fibrillation is common during
thoracic surgery

Drugs may also cause changes in cardiac rhythm eg; Halothane

and nitrous oxide may cause junctional rhythms.
Catecholamines also have potent effects on impulse conduction,

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so the interaction of halothane and exogenous or endogenous
catecholamines may cause ventricular arrhythmias. Ventricular
ectopic beats are common. However, rhythm disturbances such
as ventricular tachycardia or rarely ventricular fibrillation may
occur. The presence of cardiac disease, hypoxia, acidosis,
hypercarbia (raised CO2 level) or electrolyte disturbances
will increase the likelihood of these arrhythmias.
Arrhythmias occurring during halothane anesthesia can often be
resolved by reducing the concentration of halothane, ensuring
adequate ventilation thereby preventing hypercarbia, increasing
the inspired oxygen concentration and providing an adequate
depth of anesthesia for the surgical procedure.

Drugs increasing heart rate include ketamine, ether, atropine

and pancuronium.

Drugs decreasing heart rate include opioids, beta blockers

and halothane.

Action Plan

when faced with an abnormal rhythm on the ECG monitor

 Assess the vital signs - A.B.C.

 Check the airway is patent
 Check the patient is breathing adequately or is being
ventilated correctly
 Listen for equal air entry into both lungs
 Circulation - check pulse, blood pressure, oxygen
saturation. Is there hemodynamic compromise?
 Does the abnormal rhythm on the monitor match the pulse
that you can feel?
 Consider the following: Increase the inspired oxygen
concentration

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  Reduce the inspired volatile agent concentration
 Ensure that ventilation is adequate to prevent CO2 build
up.
 Check end tidal CO2 where this measurement is available
 Consider what the surgeon is doing - is this the cause of
the problem? Eg: traction on the peritoneum or eye
causing a vagal response. If so ask them to stop while you
treat the arrhythmia. If the arrhythmia is causing
hemodynamic instability, rapid recognition and treatment
is required. However, many abnormal rhythms
encountered in every day practice will respond to the
above basic measures - sometimes even before
identification of the exact rhythm abnormality is possible.

Body temperature
The core body temperature is tightly controlled in humans,
because all body tissues function optimally within a narrow
range of temperature. This is usually 2 to 4 degrees warmer than
the skin temperature over the limbs, which depends on many
other factors such as the ambient heat exposure, and
vasoconstriction.

When surgical operations are performed, the patient is typically

exposed to a cold environment, as well as dilution of the warm
body fluids by colder intravenous infusions. The surgical
incision also contributes to heat loss from the body via
evaporation of various fluids from the opening. However, this
alone is insufficient to induce hypothermia in a normal patient.
Instead, the normal process of thermoregulation drives up the
body heat production to maintain an even temperature.

Anesthesia can cause hypothermia if the surgical patient is not

monitored carefully. Core temperature may be directly measured
at sites such as the distal esophagus, the pulmonary artery, or the

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ear drum (tympanic membrane). However, other sites which
indicate a consistent relationship with the core temperature are
generally used for clinical purposes, such as the bladder, rectum,
or even the axilla.

Hypothermia has consistently been shown to worsen the

postoperative course of the patient, inducing complications such
as:

 Myocardial stress because the drop in core temperature

activates the sympathetic system
 Coagulation system dysfunction
 Wound infections
 Poor wound healing
 Longer hospital stays
 Patient discomfort and shivering

Spinal anesthesia can also cause hypothermia, but the fall in

core temperature may not be as marked as that following the use
of a general anesthetic. These patients are unable to sense the
hypothermia as a result of autonomic impairment, coupled with
failure of regulatory mechanisms.

Capnography
Capnography monitoring is an essential component during
anesthesia. This technology closely monitors the concentration
of carbon dioxide in exhaled breath and can help immediately
detect unexpected changes in respiration when a patient is
sedated during a procedure. This information is critical during
surgery and could potentially save a patient’s life with early
detection of cardiorespiratory problems, like hypoventilation or
inadvertent esophageal intubation.
Capnography monitoring is ubiquitous technology that has
become a standard component to anesthesia practice around the
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world. These systems tell healthcare providers how well a
patient is eliminating carbon dioxide through the pulmonary
system and can also be used to determine how well a patient is
responding to treatment. In short, the data provided by
capnography technology is absolutely critical in the operating
room for monitoring patients under general anesthesia because it
not only monitors CO2 levels but can also provide rapid
feedback that intubation has been done correctly.
Our CO2 relies on a side stream method that is appropriate for
both intubated and non-intubated patients and has simple
connection sample lines that make the system one of the lowest
costs per patient end tidal CO2 measurement systems on the
market.

End tidal CO2. Or, the maximum amount of carbon dioxide

measured at the end of expiration. It's measured using infra-red
capnography. It can help to confirm the correct positioning of
an ETT and is vital for monitoring during mechanical
ventilation. It can be used as a guide to PCO2, and different
capnography waveforms can be used as a diagnostic aid to
identify different respiratory pathologies.

A normal ETCO2 reading is 4.5-6.0kPa, or 35-45mmHg. This

is the same as the normal readings for PCO2 on a blood gas
when the patient is generally cardiorespiratory stable and
normothermic, and therefore an ETCO2 can be used to
approximate PCO2 readings. A large difference in figures could
indicate an increase in physiological dead space (ventilation of
poorly perfused alveoli, meaning areas of functional lung tissue
are not participating in gas exchange) or intra-pulmonary
shunting (lack of ventilation to perfused alveoli, meaning gas
exchange is not happening as blood passes alveoli)- these are
both forms of V/Q mismatch.
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An absent waveform can be indicative of an absent (extubated)
airway or esophageal intubation (there's no CO2 in the
esophagus), apnea or respiratory arrest (there will be no end
tidal CO2 if there is no tidal) or a ventilator disconnection.
A low ETCO2 reading can indicate a low metabolic production
of CO2 (e.g., hypothermia) or increased removal of CO2 if
someone is hyperventilating (there may be a progressive drop
in CO2 as they blow it all off).
Conversely, a progressive rise in CO2 could indicate
rebreathing CO2 (where an increase in baseline will be seen
alongside overall increases), hypoventilation, increased CO2
production due to an increased metabolic rate (e.g., fever), or an
airway obstruction leading to impaired removal of CO2 (this
will usually also present with high airway pressures).
A sudden rise in CO2 could be indicative of ROSC following
CPR for cardiorespiratory arrest, as the patient starts breathing
again. During CPR, there should be some type of waveform
present (see pic by below) which indicates good quality CPR.

Capnography
A capnography waveform has 4 phases- the inspiratory baseline,
expiratory upstroke, alveolar plateau and the inspiratory
downstroke.

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. INSPIRATORY BASELINE
Flat, as inspired gas at the beginning of expiration usually
doesn't have any CO2. If baseline is high, could indicate
rebreathing,

2. EXPIRATORY UPSTROKE
Rapid increase as alveolar gas exchange begins. O2 exchanged
for CO2 and expiration of CO2-rich gas begins.

3. ALVEOLAR PLATEAU
Usually gradually increases as alveolar gas exchange continues
during expiration. Airway obstruction will cause a greater
increase (could appear as shark fin waveform, e.g., in asthma).
ETCO2 reading taken at peak of plateau (as this is the end of
expiration).

4. INSPIRATORY DOWNSTROKE
Rapid fall in CO2 concentration as inspiration starts and O2 rich
air arrives.

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MCQ TEST
1- Anesthesia and arrhythmia(all true except one)
a) Transient supraventricular and ventricular
tachycardias due to sympathetic stimulation
during laryngoscopy and intubation.

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 b) tachycardia produced by surgical manipulation
resulting in vagal stimulation
c) Severe bradycardia and asystole may result.
d) bradycardia common in children because the
sympathetic innervation of the heart is
immature and vagal tone predominates
e) Atrial fibrillation is common during thoracic
surgery.
2- All the following are risk factors for arrhythmia
during anesthesia except one
a) The presence of cardiac disease
b) Hypoxia
c) Acidosis
d) low CO2 level
e) electrolyte disturbances
3- Progressive rise in CO2 level indicate all the
following except one
a) rebreathing CO2
b) hyperventilation
c) increased CO2 production due to an increased
metabolic rate
d) Fever
e) airway obstruction
4- A normal ETCO2 reading is
a) 4.5-6.0mmHg, or 35-45Kpa.
b) 4.5-6.0kPa, or 35-45mmHg.
c) 5.5-8.0kPa, or 45-55mmHg.
d) 2.5-5.0kPa, or 30-85mmHg.
e) 9.5-1.0kPa, or 15-45mmHg.

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