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Monitoring in Anesthesia

Monitoring in Anesthesia. พญ.เพชรรัตน์ วิสุทธิเมธีกร พ.บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว. ( วิสัญญี ) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร และวชิรพยาบาล. Topic module. 1. รู้วัตถุประสงค์และความสำคัญในการเฝ้าระวัง 2. รู้จักข้อบ่งชี้และขัอห้ามในการใช้เครื่องเฝ้าระวัง

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Monitoring in Anesthesia

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  1. Monitoring in Anesthesia พญ.เพชรรัตน์ วิสุทธิเมธีกร พ.บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว.(วิสัญญี) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร และวชิรพยาบาล

  2. Topic module • 1.รู้วัตถุประสงค์และความสำคัญในการเฝ้าระวัง • 2.รู้จักข้อบ่งชี้และขัอห้ามในการใช้เครื่องเฝ้าระวัง • 3.สามารถใช้และแปรผลค่าที่ได้จากเครื่องเฝ้าระวัง ( NIBP, SpO2 , ECG , ET-CO2 )

  3. Contents • Introduction • What is monitoring? • Which, Why and How to monitor? • Level of monitoring • Standards for basic intraoperative monitoring ( ASA) • Systematic monitoring • Conclusion

  4. Monitoring: A Definition • ... interpret available clinical data to help recognize present or future mishaps or unfavorable system conditions • ... not restricted to anesthesia (change “clinical data” above to “system data” to apply to aircraft and nuclear power plants)

  5. What is monitoring? • to monere (การเฝ้าระวัง, การเตือนภัย) • Physiologic parameter & Patient safety parameter • Clinical skills & Monitoring equipment • Data collection, interpretation, evaluation, decision • Problem seeking, Severity assessment, Therapeutic assessment, Evaluation of Anesthetic interventions

  6. Patient Monitoring and Management Involves … • Things you measure(physiological measurement, such as BP or HR) • Things you observe(e.g. observation of pupils) • Planning to avoid trouble(e.g. planning induction of anesthesia or planning extubation) • Inferring diagnoses(e.g. unilateral air entry may mean endobronchial intubation) • Planning to get out of trouble(e.g. differential diagnosis and response algorithm formulation)

  7. Level of monitoring • Routine / Specialize / Extensive • Non-equipment / Non-invasive / Minimally invasive / Penetrating / Invasive / Highly invasive • Systematic • Respiratory / Cardiovascular / Temperature/Fetal • Neurological / Neuro-muscular / Volume status & Renal • Standards for basic intraoperative monitoring ( ASA)

  8. Standards for basic intraoperative monitoring ( ASA : American Society of Anesthesiologists) Standard I • Qualified anesthesia personnel shall be present in the room throughout the conduct of all GA, RA, MAC Standard II • During all anesthetics, the patient’s respiratory (ventilation, oxygenation), circulation and temperature shall be continually evaluated

  9. Monitoring in the Past • Visual monitoring of respiration and overall clinical appearance • Finger on pulse • Blood pressure (sometimes)

  10. Monitoring in the Past Finger on the pulse

  11. Harvey Cushing Not just a famous neurosurgeon … but the father of anesthesia monitoring • Invented and popularized the anesthetic chart • Recorded both BP and HR • Emphasized the relationship between vital signs and neurosurgical events( increased intracranial pressure leads to hypertension and bradycardia )

  12. Examples of Multiparameter Patient Monitors

  13. Transesophageal Echocardiography Depth of Anesthesia Monitor Evoked Potential Monitor Some Specialized Patient Monitors

  14. Cardiovascular monitoring • Routine monitoring • Cardiac activity • Non-invasive blood pressure ( NIBP ) • Electrocardiography ( ECG ) • Advanced monitoring • Direct arterial blood pressure • Cardiac filling pressure monitor • Central venous pressure • Pulmonary capillary wedge pressure

  15. Cardiovascular monitoring • Electrocardiography • Cardiac activity • Arrhythmia: Lead II • Myocardial ischemia: ECG criteria • Electrolyte imbalance • Pacemaker function

  16. Cardiovascular monitoring • การบ้าน ECG 1. การติด lead II, modified V5 2. การแปรผล สาเหตุ การรักษา -arrhythmia : bradycardia, tachycardia, AF, PVC, VT, VF -Myocardial ischemia -electrolyte imbalance

  17. Cardiovascular monitoring • Non-invasive blood pressure (NIBP) • Cuff: width 120-150 % limb diameter, air bladder includes more than halfway around limb • Manometer: aneroid, mercury • Detector: manual, automated การบ้าน หลักการทำงาน หลักการเลือกขนาด ค่าที่ได้ ค่าใดถูกต้องและเชื่อถือได้มากที่สุด สถานะการณ์ใดรบกวนการวัดและรบกวนอย่างไร

  18. Cardiovascular monitoring • Non-invasive blood pressure • Inaccurate: cuff size, inflated pressure, shivering, cardiac arrhythmia, severe vasoconstriction Proper application Narrow cuff Loose cuff

  19. Cardiovascular monitoring • Direct arterial pressure monitor • Indications • Continuous blood pressure monitor: anticipated cardiovascular instability, direct manipulation of cardiovascular system, inability to accurate measurement directly • Frequent arterial blood sampling: ABG, Acid-base / electrolyte / glucose disturbance, Coagulopathies

  20. Cardiovascular monitoring • Direct arterial pressure monitor • Contraindications • Local infection • Impaired blood circulation: Raynaud’s phenomenon, DM • Risks of thrombosis: hyperlipidemia, previous brachial artery cannulation • Modified Allen’s test ??? ( การบ้านข้อที่เท่าไรแล้วคะ)

  21. Cardiovascular monitoring • Direct arterial pressure monitor • Complications • Direct trauma: AV-fistula, Aneurysm • Hematoma • Infections • Thrombosis • Embolization • Massive blood loss

  22. Cardiovascular monitoring • Cardiac filling pressure monitor • Frank-Starling curve: optimum Preload maximize ventricular performance (Stroke volume, CO.) • Preload = Myocardial fiber length (2.2 micron) • LV Preload  LVEDV  LVEDP  LAP  PCWP  PAP RVP  RAP  CVP • Myocardium function, LV compliance, Mitral valve, Airway pressure, Pulmonary vascular resistance, Pulmonic valve, Tricuspid valve

  23. Cardiovascular monitoring • Cardiac filling pressure monitor • LV Preload  LVEDV  LVEDP  LAP  PCWP  PAP • LVEDP  RVEDP  RAP  CVP

  24. Cardiovascular monitoring • Cardiac filling pressure monitor • PCWP: Pulmonary capillary wedge pressure • CVP: Central venous pressure

  25. Cardiovascular monitoring • PCWP: Pulmonary capillary wedge pressure • CVP: Central venous pressure • Fluid Challenge test to optimize preload and maximize Cardiac performance

  26. Respiratory monitoring • Ventilatory monitoring • Oxygenation monitoring • Machine and Circuit monitoring • Clinical skills • Monitoring devices

  27. Ventilatory monitoring • Clinical skills • Direct observation: rate, rhythm, volume of respiration • Auscultation: precordial, esophageal stethoscope • Palpation: reservoir bag movement • Monitoring devices • Spirometer • Airway pressure manometer • Circuit disconnection alarm

  28. Ventilatory monitoring • Capnometer (End-tidal CO2 analysis) • relationship with PaCO2 : ETCO2 < PaCO2 ~ 3-6 mmHg • mainly depends on dead space ventilation • normal value 30 – 35 mmHg • Infrared absorption spectrography • Main-stream VS. Side-stream

  29. Ventilatory monitoring • Capnogram : normal curve • 1. Dead space air (no CO2) • 2. Mixed bronchus & alveolus air (CO2 upstroke) • 3. Alveolus air (CO2 plateau) Inspiration ETCO2 3 2 1

  30. Ventilatory monitoring • Capnometer (End-tidal CO2 analysis) • Most useful in detection of Esophageal intubation, airway or circuit disconnection • Useful in CO2 rebreathing, partial recovery of neuro-muscular blockade, good predictor of successful CPR

  31. การบ้าน (เขียน waveform of ET-CO2 และสาเหตุ) • Capnograph -esophageal intubation -bronchial intubation -airway obstruction -circuit disconnect -circuit leakage -partial rebreathing -spontaneous breathing (recovary of neuromuscular blockade) -hypoventilation

  32. Oxygenation monitoring • Clinical skills • Direct observation: impaired mental function, sympathetic overactivities, appearance(+ cyanosis) • Auscultation: wheezing, crepitation • Monitoring devices • Arterial blood gas analysis • Percutaneous O2 measurement • Pulse oximeter

  33. Oxygenation monitoring • Pulse oximeter • Percent of oxyhemoglobin / total hemoglobin • Oxyhemoglobin absorp 940 nm. • Deoxyhemoglobin absorp 660 nm. • Caution: SpO2 PaO2

  34. Oxygenation monitoring • Pulse oximeter • SpO2correlates with PaO2 as in Oxygen-hemoglobin dissociation curve • SpO2 90  PaO2 60 mmHg (moderate hypoxemia) 75  40 mmHg (mixed venous oxygen sat.) 50  27 mmHg (P50)

  35. Oxygenation monitoring • Pulse oximeter artifacts • Abnormal hemoglobin: COHb, MetHb, HbF • Dye: Methylene blue • Anemia • Ambient light • Arterial saturation • Blood flow • Motion • Nail polish • Electro-cautery

  36. การบ้าน • Wave form Pulse oximeter • Pulse oximeter artifacts กระทบต่อการแปรผลอย่างไร • Cause of Rt-Lt shift of oxygen-hemoglobin dissociation curve

  37. Machine & circuit monitoring • Safety system • DISS, PISS, Quick disconnection adaptor • Oxygen fail-safe valve, Oxygen supply failure alarm • Oxygen analyzer • Airway gas composition • Clinical skills: flowmeters, vaporizers • Monitoring devices: Infrared spectrometer

  38. Depth of Anesthesia • Clinical Signs • eye signs • respiratory signs • cardiovascular signs • CNS signs • EEG monitoring • Facial EMG monitoring (experimental) • Esophageal contractility (obsolete)

  39. Neurologic monitoring • Depth of anesthesia ( BIS ) • EEG • Evoked potentials • Cerebral blood flow • Intracranial pressure

  40. Neuromuscular monitoring • Clinical skills • Monitoring device : PERIPHERAL NERVE STIMULATOR

  41. Volume status and renal monitoring • Estimate blood loss • Urine output • Hemodynamic stability

  42. Volume status and renal monitoring • Estimate blood loss • Urine output • Hemodynamic stability

  43. Electrolyte / Metabolic monitoring • Fluid balance • Sugar • Electrolytes • Acid-base balance

  44. Coagulation Monitoring • PT / PTT / INR • ACT • Platelet counts • Factor assays • TEG • Clinical sign

  45. Temperature monitoring • 4 mechanism of heat loss • Perioperative hypothermia (BT<36) • Core temperature : nasopharynx, esophageal, tympanic membrane, pulmonary a. catheter, bladder, rectum

  46. Temperature Monitoring Rationale for use • detect/prevent hypothermia • monitor deliberate hypothermia • adjunct to diagnosing MH • monitoring CPB cooling/rewarming

  47. Temperature monitoring • Deleterious effects of hypothermia -cardiac dysrhythmia -increased PVR -Lt. shift of the Oxygen-hemoglobin dissociation curve -reversible coagulopathy (platelet dysfunction) -postoperative protein catabolism and stress response -altered mental status -impaired renal function -decreased drug metabolism -poor wound healing

  48. Conclusionการบ้านกี่ข้อแล้วคะมีเครื่องมือเยอะจังไม่ได้อย่า out ต้องรู้ NIBP,ECG,ET-CO2,SpO2

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