MONITORING IN ANESTHESIA respiratory, neurological

monitoring in anesthesia

1. MONITORING IN Presented by:-DR.KALYAN REGMI Moderator :- PROF.DR MAYA LAMA ANAESTHESIA

2. OBJECTIVES To know the important of monitoring in anesthesia. ASA Standards guideline for Basic Anesthetic Monitoring. Different types of monitoring device and there uses.

3. - Monitoring is an essential part of anesthesia care - The term is derived from monere,Latin word- means - to warn, remind. - In anesthesia, monitoring means using both our senses & electronic device to repeatedly or continuously measure important variables in anaesthesized pt. MONITORING

4. WHY MONITORING IS IMPORTANT ?? To monitor physiological homeostasis ,prompt recognition of adverse changes To look responses to therapeutic intervention To know either anesthetic equipment is Properly functioning or not Prompt response to adverse changes

5. - Standard I - Qualified anesthesia provider will be present with the patient throughout the anesthetic procedure Standard II – Patient oxygenation, ventilation, circulation, and temperature should be continually monitored. The ASA Standards for Basic Anesthetic Monitoring

6. -Assessment of oxygenation involves two parts: measurement of inspired gas with an oxygen analyzer and assessment of hemoglobin saturation with a pulse oximeter and observation of skin color - Assessment of ventilation is by clinical assessment and preferably capnography

7. MONITORING DURING ANESTHESIA BASIC MONITORING Basic monitoring is based on visual inspection Auscultation Palpation which primary determine patient safety. Any changes in clinical signs  often precede abnormalities in parameters measured by monitoring devices.

8. They include:- 1.PULSE RATE 2.CHEST INFLATION 3.BLOOD PRESSURE 4.COLOR OF SKIN 5. SYMPATHETIC OVERACTIVITY 6. URINE OUTPUT

9. ADVANCE (INSTRUMENTAL ) MONITORING Advance monitoring does not replace clinical observation ; rather, they amplify and quantify clinical information. Advance monitoring include CARDIOVASCULAR MONITORING RESPIRATORY MONITORING NEUROMUSCULAR MONITORING CNS MONITORING TEMPERTURE MONITORING

10. CARDIOVASCULAR MONITORING NON-INVASIVE - ECG MONITORING: Voltage time graph of electrical activities of heart. Indication 1.To detect arrhythmia, ischemia, cardiac arrest. 2. To detect electrolyte alternation .

11. -NON-INVASIVE BLOOD PRESSURE MONITORING: Measure blood pressure at set interval automatically by automated oscillometry . Cuff sized should cover 2/3 rd of arm

12. 2. SEMI-INVASIVE - TRANESOPHAGEAL ECHOCARDIOGRAPHY: A transesophageal echocardiogram is done by inserting a probe with a transducer down the esophagus. This provides a clearer image of the heart because the sound waves do not have to pass through skin, muscle, or bone tissue. Detect ischemia, air embolism ,valvular dysfunction etc

13. 3. INVASIVE - INVASIVE BLOOD PRESSURE : Beat to beat monitoring of blood pressure via catheterization of artery i.e radial artery, ulnar artery, femoral artery , brachial artery etc -CENTRAL VENOUS PRESSURE : Measured by catheterization over the right internal jugular vein. Normal value 2-6 mmHg. Other sites: subclavian vein ,femoral vein

14. Indication:- Continuous central venous pressure monitoring Open heart surgery Fluid management in shock Parenteral nutrition Venous access

15. Contraindication Coagulopathy Heart block Infection around insertion site Tricuspid vegetation

16. Complication: Infection Thromboembolism Vascular injury Respiration : pneumnothorax ,hemothorax Nerve injury: brachial plexus , phernic nerve Arrhythmia

17. -PULMONARY ARTERY CATHETERIZATION : Catheterization of pulmonary artery via Swan Ganz catheter by internal jugular vein . Indication:- Pulmonary artery hypertension Fluid management in shock Measure cvp , left atrial pressure ,pulmonary capillary wedge pressure Evaluate pericardial illness like cardiac tamponade , constrictive pericarditis Cardiac output Venous access

18. Contraindication:- Coagulopathy Heart block Infection around insertion site Tricuspid vegetation

19. Complication: Infection Thromboembolism Vascular injury Respiration : pneumnothorax ,hemothorax Nerve injury: brachial plexus , phernic nerve Tricuspid regurgitation, arrhythmia, right bundle branch block

20. RESPIRATORY MONITORING 1.PULSE OXIMETRY:- Measure oxygen saturation of hemoglobin and pulse rate on non-invasive and continuous basis. Based on Beer-Lambert law -Pulse oximetry combines the technology of plethysmography and spectrophotometry . -Pulse oximetry helps to detect hypoxia.

21. LIMITATION OF PULSE OXIMETRY False high spo2 seen in Presence of abnormal Hb like carboxyhemoglobin , methemoglobin False low spo2 seen in Nail polish Dark skin High venous pressure

22. 2 . CAPNOGRAPHY -Non-invasive measurement of partial pressure of CO2 in exhaled breath expressed as CO2 concentration over time. -Determination of end-tidal CO2 (ETCO2 ) concentration. -Surest sign for confirming right placement of tube

23. 3.BLOOD GAS ANALYSIS Measure the amount of arterial gases (o2 and co2) and Ph NORMAL INTERPETATION

24. HOW TO INTERPRET ABG 1. PH Less than 7.35 = acidemia More than 7.45 = alkalemia 2. Look for co2

25. ABG INTERPRETATION

26. 4.OXYGEN ANALYZER Fitted in inspiratory in limb of breathing circuit Monitor acutal value of oxygen delivered Used in closed circuit

27. 5.AIRWAY PRESSURE MONITORING Airway pressure should be less than30 cm of h20 Low pressure : indicated disconection High pressure :indicated obstrution

28. 6. APNEA MONITORING Cessation of respiration >10 sec INTUBATED PATIENT - Capnography -Airway pressure monitoring - Pulseoximeter NON-INTUBATED PATIENT Airflow at nostril -Chest movement -Pulse oximeter

29. NEUROMUSCULAR MONITORING -Detecting the onset of paralysis during induction Adequacy of block Plan for extubation 1. TRAIN OF FOUR 4 stimuli ,each of 2Hz for 2 sec are given and recorded. -Normal: amplitude height of 4 th and 1 st twitches will be same i.e T4/T1=1 -Twitches fade as nondepolarizing muscle relaxant block increase.

30. -Disappearance * fourth twitch- 75% block * the third twitch- 75% to 80% block * second twitch- 80 to 90% block

31. OTHERS - Tetanic stimulation - Double burst stimulation

32. CENTRAL NERVOUS SYSTEM MONITORING 1.ELECTROENCEPHALOGRAPHY (EEG) Indications- Cerebrovascular surgery to confirm the adequacy of cerebral oxygenation. -symmetry between the left and right hemispheres. -To detect areas of cerebral ischemia

33. Techniques- -Electrode position (montage) is governed by the international 10–20 system

34. WAVES OF EEG

35. Examine four components- (1) Low frequency, as found during deep anesthesia (2) High-frequency beta activation found during “light” anesthesia (3) Suppressed EEG waves (4) Burst suppression. 2.BISPECTRAL INDEX (BIS)

36. TEMPERATURE MONITORING Indications 1)Hypothermia -is associated with delayed drug metabolism, increased blood glucose, vasoconstriction, impaired coagulation, and impaired resistance to surgical infections. 2)Hyperthermia - have deleterious effects perioperatively , leading to tachycardia, vasodilation , and neurological injury.

37. Thermocouple Thermistor Intraoperatively , measured using a thermistor or thermocouple.

38. URINE OUTPUT MONITORING -Urinary bladder catheterization is the most reliable method of monitoring urinary output -Catheterization is routine in cardiac surgery, aortic or renal vascular surgery, craniotomy, major abdominal surgery in which large fluid shifts are expected -Lengthy surgeries and intraoperative diuretic administration

39. NORMAL URINE OUTPUT : 1-2ml/kg/hours OLIGOURIA : <0.5ml/kg/hours ANUIRA : <100ml/day

40. COMPLICATION OF URINARY CATHERERIZATION Urethral trauma Urinary tract infection Hematuria

41. TAKE HOME MESSAGE Anaesthesiologist must be with the patient throughout the anesthetic procedure. Effective monitoring decrease poor outcome.

42. THANK YOU