Monitoring Of Critically ill Patient

• The aim of monitoring patients is to detect organ dysfunction and guide the
restoration and maintenance of tissue oxygen delivery. Monitoring is a
crucial part of the care of the critically ill patient in the emergency
department as the physiological response to critical illness is linked strongly
to outcome.
• Critical Care Unit (CCU) equipment includes patient monitoring,
respiratory and cardiac support, pain management, emergency
resuscitation devices, and other life support equipment designed to care
for patients who are seriously injured, have a critical or life-threatening
illness, or have undergone a major surgical procedure, thereby requiring
24 hour care and monitoring.

Temperature Monitoring:
• Peripheral temperature reflects tissue perfusion and is affected by
vasoconstriction and low cardiac output. Core temperature may be
monitored by placing a deep rectal or esophageal thermometer.
Thermistors are used commonly for monitoring core temperatures and are
Lead I: (RA) It helps assess the
heart s electrical activity from the
perspective of the right side of the
body.
based on the principle of changing resistance with temperature.
Lead II: (LA) It helps assess the
heart s electrical activity from the
perspective of the left side of the
body.
• When monitoring the temperature early recognition of hypo or
hyperthermia will result as well as trends in the patient's status. In the
Lead III: (LL) It helps assess the
heart s electrical activity from the
perspective of the lower part of the
body.

neonate the normal body temperature is 7°F above the environmental

Einthoven Triangle
temperature during the first week of life. By the second week they can
maintain their temperature from 98 - 100°F. By the forth week their
thermal regulation is mature.

Cardiovascular System Monitoring:

Cardiac Monitoring:
• Most critical care patients have cardiac activity monitored by a 3 - lead
system; signals are usually sent to a central monitoring station by a small
radio transmitter worn by the patient. Automated systems generate alarms
for abnormal rates and rhythms and store abnormal tracings for
subsequent review.
• Some specialised cardiac monitors track advanced parameters associated
with coronary ischemia. These parameters include continuous ST Segment
Monitoring and Heart Rate Variability. Loss of normal beat-to-beat
variability signals a reduction in autonomic activity and possibly coronary
ischemia and increased risk of death.

Heart Rate Monitoring:

• Heart rate is a nonspecific parameter. It is usually measured by
auscultation of the heart and palpation of an artery, automatically taken
from an ECG or arterial pulse pressure wave. Increase in heart rate
(tachycardia) may be caused by Hypovolaemia, fever, excitement,
exercise and pain.
• Tachycardia is generally defined as a heart rate greater than 160 beats
per minutes (bpm). Decrease in heart rate (bradycardia) may be caused
by high severe electrolyte disturbances and Atrioventricular Conduction
Blocks. Bradycardia is generally defined as a heart rate less than 60 bpm.

Heart Rhythm:
• When irregularities in heart sounds are heard, the heart rate should be
compared to pulse rate and the difference in rates are called Pulse
Deficits. Pulse deficits are indicative of Arrhythmias. Hypoxia, Myocardial
Contusions and metabolic or acid base imbalance may cause arrhythmias.
• Some examples of cardiac arrhythmias include: Premature Atrial
Contraction (PAC), Atrial Fibrillation, Premature Ventricular Contraction
(PVC) and Ventricular Tachycardia. All pulse abnormalities should be
confirmed by Electrocardiogram (ECG).

Electrocardiographic Monitoring:
• The ECG reflects the electrical activity of the heart. The ECG detects the
voltage difference at the body surface and amplifies and displays the
signal.
• The ECG provides useful information about Ischemia, Arrhythmias, and
Electrolyte Imbalance and Drug Toxicity. Standard bipolar leads I, II and
III have a limited role in detecting ischemia. Modification of these leads
(CM5 lead) can detect arrhythmias as well as ischemia.

Mucous Membrane Colour and Capillary Re ll Time:

• The normal mucous membrane colour is pink. In diseased states the MM
colour may be yellow, pale, white, brick red or blue. Capillary Refill Time
(CRT) is an indication of peripheral perfusion and should not be thought of
as an indicator of blood pressure. CRT is the rate at which blood returns to
the capillary bed after it has been compressed digitally.
• To measure CRT lift up the lip and compress the gum with your finger until
it blanches out, when you release the pressure the gums should return to
their original colour within 1-2 Sec. Prolonged CRT is due to
Vasoconstriction. Vasoconstriction may be caused by Hypovolemia,
excitement, fear & pain.

Central Venous Pressure Monitoring:

• Central venous pressure (CVP) is a measurement of right atrial pressure. It
evaluates three things:
• The heart's ability to function as a pump.
• Blood volume in relation to volume capacity.
• Vasomotor tone.
The normal CVP level is 0-10 Cm H2O.
• Measuring CVP involves a thin, flexible tube called a catheter being
inserted into a vein in your neck (jugular vein) and carefully guided into
the superior vena cava, a large vein leading to your right atrium. The
pressure is then measured using a specialised device called a water
manometer or Manometer Synchronous.

Arterial Blood Pressure Monitoring:

• Blood pressure measurement is a valuable monitoring tool when evaluated
with other cardiovascular parameters. Blood pressure is a product of
Cardiac Output, Vascular Capacity and Blood Volume. These three
components are in a careful balance; impairment of one of the components
is usually compensated for by the other two so as to maintain adequate
blood pressure.
• The systolic pressure is the maximal pressure obtained with each cardiac
ejection. The diastolic pressure is the minimal pressure prior to the next
ejection cycle.
• There are two methods of blood pressure measurement, direct and indirect.
Indirect methods of measuring blood pressure include palpation,
auscultation and oscillotonometry. Direct arterial pressures can be
recorded by inserting a cannula in the radial, femoral or dorsalis pedis
artery and connecting it to a zeroed and calibrated transducer which
converts pressure energy into electrical signals.

Pulmonary Artery Catheter Monitoring:

• Pulmonary artery catheter monitoring involves placing a catheter into the
pulmonary artery. This allows continuous tracking of various
cardiovascular parameters like pulmonary artery pressure, cardiac output,
and central venous pressure. It provides crucial insights into a patient's
cardiac function and fluid status, aiding in the management of critical
conditions.

Pulmonary Artery Occlusion Pressure (PAOP):

• This procedure helps doctors measure the pressure in your left atrium, the
chamber that receives blood from your lungs before pumping it out to the
rest of your body.

How does it work?

Insertion: The catheter is inserted into a large vein, like the one in your neck
or chest.

Tip Inflation: Once the tip reaches the right ventricle of your heart, the
balloon is briefly inflated with a small amount of air.

Moving Forward: While monitoring the pressure changes, the catheter is

carefully advanced until it reaches a small branch of the pulmonary artery.

Wedge Formation: The balloon traps a column of blood, creating a "wedge"

that reflects the pressure in the left atrium.

Pressure Measurement: This pressure, known as the pulmonary artery

occlusion pressure (PAOP), is displayed on a monitor.

What does PAOP tell us?

Normal PAOP: Typically between 8 and 12mmHg, indicating good left

ventricle function.
High PAOP (above 18mmHg): suggests that your heart is struggling to pump
blood efficiently, potentially due to conditions like heart failure.

Thoracic Bio-impedance:
• These systems use topical electrodes on the anterior chest and neck to
measure electrical impedance of the thorax. This value varies with beat-to-
beat changes in thoracic blood volume and hence can estimate CO.
• The system is harmless and provides values quickly (within 2 to 5 min);
however, the technique is very sensitive to alteration of the electrode
contact with the patient.

Esophageal Doppler Monitor (EDM):

• The Esophageal Doppler Monitor (EDM) is a soft 6-mm catheter placed
through the nose into the oesophagus, positioned behind the heart. It
features a Doppler flow probe at its tip for continuous monitoring of
cardiac output (CO) and stroke volume.
• In contrast to the invasive Pulmonary Artery Catheter (PAC), the EDM
avoids complications like pneumothorax, arrhythmias, or infections. It
might offer enhanced accuracy in patients with certain heart conditions.
However, its reliability is sensitive to slight position changes, potentially
causing dampened and inaccurate readings due to waveform loss.

Toe Web-Rectal Temperature:

• It has been shown that skin temperature correlates well with peripheral
perfusion and cardiac output. An excellent and non-invasive technique for
monitoring peripheral perfusion is the toe web - rectal temperature.
Measurements are made with an electronic thermometer, thermistor probe
or a mercury thermometer.
• Point-of-care testing uses miniaturised, highly automated devices to do
certain blood tests at the patient's bedside or unit (particularly ICU,
emergency department, and operating room). Commonly available tests
include blood chemistries, glucose, ABGs, CBC, cardiac markers, and
coagulation tests. Many are done in < 2 min and require < 0.5 mL blood.

Haematocrit and Haemoglobin Concentration Monitoring:

• Monitoring hematocrit and hemoglobin concentration is crucial for
assessing the blood's oxygen-carrying capacity and thickness. Hematocrit
indicates the percentage of red blood cells in the blood, influencing its
viscosity. While lower hematocrit may improve peripheral blood flow, it
can compromise oxygen delivery. The ideal hematocrit for critically ill
patients is often around 35%, with a target hemoglobin concentration of
12-14 g/dL.
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