Done by Heba Abu Khalaf Objectives 1 Guidelines to the practice of anesthesia and patient monitoring 2 Anesthesia depth 3 Elements to monitor Oxygenation Ventilation Circulation Temperature ID: 785017
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Slide1
Monitoring in AnesthesiaDone by : Heba Abu Khalaf
Slide2Objectives 1. Guidelines to the practice of anesthesia and patient monitoring2. Anesthesia depth3. Elements to monitor (
Oxygenation, Ventilation, Circulation, Temperature)
2.1. ECG
2.2. Pulse Oximetry
2.3. Blood Pressure
2.4. central venous line and pressure
2.5.
Capnography
and EtCO2
2.6.
How to identify Cyanosis
2.7. The oxyhemoglobin dissociation curve
3. Normal values for a healthy adult undergoing anesthesia
Slide3Guidelines to the practice of anesthesia and patient monitoring:1. an anesthetist present: “the only indispensable monitor” The doctor should present in the room & monitor the conduct of all general or regional anesthetics2.
A completed pre-anesthetic checklist.
(ASA class, Hx &physical exam, investigations, NPO policy )
Slide4Con’t... 3. perioperative anesthetic record: HR and BP every 5 min, O2 saturation, End Tidal CO2, dose and route of drugs and fluids 4. continuous monitoring: patient’s oxygenation, ventilation, circulation and temperature .
Slide5Elements to Monitor :I. Anesthetic Depth:Patients with local or regional anesthesia provide verbal feedback regarding well being.•Onset of general anesthesia signaled by lack of response to verbal commands
, in addition to
loss of blink reflex to light touch.
Inadequate anesthesia
can be
signaled by
:
Facial grimacing or movement of arm or leg.
//
blink reflex
present when eyelashes lightly touched,
But with muscle relaxants ( fully paralysis), it can be signaled by :
Hypertension, tachycardia, tearing or sweating. { Due to pain }
Slide6Con’t... Excessive anesthesia can be signaled by : Cardiac depression, bradycardia, and
Hypotension
. also may result in
hypoventilation, hypercapnia and hypoxemia when muscle relaxants is not given.
Slide72. Oxygenation >> inspired Oxygen we monitor it Clinically through observation of patient / skin color also by :1) pulse oximetry ( SaO2 ) 2) Blood gas analysis ( Pao2 ) 3) fraction of inspired O2 (FiO2)Quantitavely
monitored by using
oxygen analyzer,
equipped with an audible low oxygen concentration alarm
.
Slide8• Pulse Oximetry: ** mandatory monitor for any anesthetic ,, including cases of moderate sedation **measure { non invasively} pt’s SpO2 ( arterial oxy saturation)And blood flow fluctuation by plethysmograph (waveform of pulse oximeter “arterial waveform “ >> indicates that pulse oximeter is reading the arterial
oxy
saturation
Slide9Technique >> sensor containing light sources (Red and Infra-red light) & light detector is placed across finger tip , toe , earlobe or any other perfused tissue that can be
transillumintaed
processing >>analyze amount of light absorbed by the 2 wavelengths,, then determining concentrations of oxygenated and deoxygenated forms through only arterial blood
light absorption is differ between
oxyHb
and
deoxyHb
.
analysis of oxygenation in each beat
Slide10Also it provides an indication of tissue perfusion & measure heart rate Inaccurate measurements ,, causes of oximetry artifact :
1) poor tissue perfusion (shock & hypotension)
2) movement
3)dysrhythmias
4) hypothermia ( cold extremities )
5) cardiac arrest
•
Pulse oximetry (SpO2) measures
oxy
-,
deoxy
-, met-, and
carboxyHb
.
Slide11Pulse oximetry is never used for rapid diagnosis of hypoxia ( that may occur in unrecognized esophageal intubation ) It used for monitoring oxygen delivery to vital organs Also in recovery room , it helps identify post op pulmonary problems such as hypoventilation / bronchospasm / atelactasis So timing of Spo2
monitoring >> before intubation , through the surgery ,, after
extubation
& recovery
Slide12Pulse oximeter tone changes with desaturation from high to low(deep) sound So just by listening to the monitor ,,you can recognize the 1) HR. 2) O2 saturation Healthy patient under GA (O2= 100%) >> Spo2 96-100%
Slide13Rules :# pay attention to the sound of pulse oximetry # Always remember that your clinical judgment is much more superior to the monitor ,, check pt’s color for cyanosis ,, lips ,, nails
Slide144.Temperature** should be monitored for patients under anesthesia ** post op temp. >> used as quality anesthesia indicator ** hypothermia associated with : 1) delay drug metabolism, 2) impaired coagulation ** hyperthermia has bad effects peri operatively leading to : 1) tachycardia 2) vasodilation 3) neurological injury So temp. Must be measured & recorded peri operatively
Slide15Hypothermia (<36°C) Normal heat loss during anesthesia averages 0.5 - 1 C per hour, but usually not more that 2-3 C Temperature below 34C may lead to significant morbidity Hypothermia develops when thermoregulation fails to control balance of metabolic heat production and environment heat loss Normal response to heat loss is impaired during anesthesia • Those at high risk are elderly, burn patients , spinal cord injuries
Slide16Causes of Hypothermia (<36°C) **intraoperative temperature losses are common (e.g. 90% of intraoperative heat loss is transcutaneous)>> due to: 1) OR environment (cold room, IV fluids, instruments) 2) open wound ## prevented with forced air warming blanket and warmed IV fluids
Slide17Impact of Hypothermia 1) Increased risk of wound infections >> due to impaired immune function2) Increases the period of hospitalization by delaying healing 3) Reduces platelet function and impairs activation of coagulation cascade increasing blood loss and transfusion requirements4) Decreases the metabolism of anesthetic agents prolonging post-operative recovery
Slide18Causes of Hyperthermia (>37.5-38.3ºC) 1) malignant hyperthermia 2) drugs (e.g. atropine)3) blood transfusion reaction 4) infection/sepsis5) • Increases in metabolic rate secondary to:–Thyrotoxicosis–Pheochromocytoma 6) Excessive environmental warming
Slide19Continuous temperature measurements monitoring (Thermometry) is mandatory if changes in temperature are suspected. ** intra op ,, temp measured by thermistor or thermocoupleMonitoring sites : >> esophagus>> tympanic membrane >> nasopharynx. >> Peripheral sites axilla & rectal.
Slide202. Ventilation Clinically, monitored through a correctly positioned endotracheal tube, also observing chest expansion and breath sounds over both lungs.
•
Quantitavely
by ETCO2 analysis, equipped with an audible disconnection alarm.
•Arterial blood gas analysis for assessing both oxygen and ventilation.
Slide213. Circulation Clinically monitored by pulse palpation, heart auscultation & monitoring intra-arterial pressure (MAP normally between 70 - 100 mmHg) or oximetry. Quantitively using ECG & blood pressure measurements every 5 min.
Slide22Typical anesthesia monitor
Slide23Always remember that your clinical judgment is much more superior to Any monitor monitor is present to help you not to be ignored and not to cancel you brain.
Slide24Thank You