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Patient monitoring

The document outlines the evolution and current standards of patient monitoring in anesthesia, emphasizing the importance of qualified personnel and continuous monitoring of vital parameters such as oxygenation, ventilation, circulation, and temperature. It details various monitoring methods, including pulse oximetry, capnography, and electrocardiograms, along with their objectives, applications, and limitations. The document concludes with a reminder to actively observe, feel, and listen during patient monitoring.

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20 views21 pages

Patient monitoring

The document outlines the evolution and current standards of patient monitoring in anesthesia, emphasizing the importance of qualified personnel and continuous monitoring of vital parameters such as oxygenation, ventilation, circulation, and temperature. It details various monitoring methods, including pulse oximetry, capnography, and electrocardiograms, along with their objectives, applications, and limitations. The document concludes with a reminder to actively observe, feel, and listen during patient monitoring.

Uploaded by

S S
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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PATIENT MONITORING

Col.Dr. Bhuban Raj Kunwar,


HOD, Dept ofAnaesthesia
Shree Birendra Hospital
MONITORING IN THE PAST
• Visual monitoring of
respiration and overall
clinical appearance
• Finger on pulse
• Blood pressure (sometimes)
CLASSIFICATION
• Non-invasive or invasive monitors
• According to target organ system
MONITORING IN THE PRESENT
ASA GUIDELINES
STANDARD I
• Qualified personnel shall be present in the operating
room throughout all:
• General Anaesthetics
• Regional Anaesthetics
• Monitored Anaesthesia Care
• Temporary Absence Exceptions:
• hazardous conditions for anesthesia provider
• provide for remote monitoring
• emergency situations
STANDARD II
• During all anaesthetia, the following parameters will
be continually monitored:
– Oxygenation
– Ventilation
– Circulation
– Temperature
OXYGENATION
• Objective
– ensure adequate oxygen concentration in
inspired gas and blood
• Methods
– inspired gas oxygen analyzer with alarms (GA)
– pulse oximetry
– illumination and exposure to assess color
Pulse Oximetry
• Theory
– two wavelengths (660 and 940 nm)
– calculates functional saturation (physiologic saturation)

• Components:
– Pair of small light-emitting diodes (LEDs)
– photodiode
• Limitations
– dyes or other hemoglobin species (carboxy, met, fetal, etc)
– motion
– low perfusion states
– electrocautery
– ambient light
VENTILATION
• Objective
– ensure adequate ventilation of patient

• Methods
 qualitative clinical signs
 chest excursion
 observation of reservoir bag
 auscultation of breath sounds

 quantitative measurement
 end tidal carbon dioxide
 volume of expired gas
 continuous circuit disconnect monitor for mechanical ventilation
Capnography
• Theory
– main or sidestream sampling
– several technical methods available
• Infrared, raman gas scattering, mass or
photoacoustic spectroscopy

• Applications
– confirmation of intubation
– monitoring for circuit disconnection
– identification of airway obstruction
– rebreathing / metabolic monitoring
Capnograph
CIRCULATION
• Objective
– ensure adequacy of circulatory function
• Methods
– continuous electrocardiogram monitoring
– arterial blood pressure and heart rate in 5 min
– during GA, one additional continual parameter:
• palpation of pulse
• Auscultation of heart sound
• intra-arterial pressure trace
• doppler peripheral pulse
• pulse plethysmography
• pulse oximetry
Non-invasive blood pressure
• Methodology
palpatory methods
Auscultatory methods
Oscillometry
• Limitations
– cuff size
• Oversize, erroneously low measurements
• too small, erroneously high
Invasive blood pressure
• Beat to beat blood
pressure monitoring
• Hemodynamically
vulnerable patient
• Deliberate
hypotension
• Frequent blood gas
analysis
Electrocardiogram
• 3 vs. 5 electrode system
• Heart rate measurement
– R wave counting (any lead)
• Ischemia Monitoring
– lead II and V5 are 90% sensitive
• Arrhythmia monitoring
– lead II for supraventricular arrhythmias
– all leads for ventricular arrhythmias
TEMPERATURE
• Objective
– aid in maintaining appropriate body temperature

• Application
– readily available method to continuously monitor
temperature if changes are intended, anticipated or suspected

• Method
– thermistor
– location
NEUROMUSCULAR FUNCTION
Evaluation of reversal of blockade
• Clinical Criteria
– head lift > 5 seconds
– sustained hand grip
– Obeys verbal command

• T4:T1 ratio > 0.9: Gold standard


Central venous pressure
• Central vein cannulation
BISPECTRAL INDEX (BIS)
• Bispectral analysis of the EEG

• Dimensionless number of 0 – 100 that represents a


level of consciousness between very deep and fully
awake

• 100: normal cortical electrical activity

• 0: cortical electrical silence

• 60 – 40: Surgical anaesthesia


OTHER’S MONITORING
• Urine output
• Blood loss
• Arterial blood gas analysis
• Blood tests in specific conditions
• Coagulation monitoring
• ICP monitoring
TAKE HOME MESSAGE
• LOOK
• FEEL
• LISTEN
THANK YOU

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