Perioperative monitoring

1
Perioperative monitoring

• Intern ???
• Miller's Anesthesia, 6th ed.
• Ognjen Gajic and Rolf D. Hubmayr

2
Cardiopulmonary MONITORING

• The anesthesiologist's senses capture more
  information than even the most sophisticated
  electronic monitors .
• Inspection, palpation and auscultation

3

• Monitoring end-organ function reflects the
  cardiovascular system
• Mucous membranes, skin color, and skin turgor can
  reveal pertinent clues about hydration,
  oxygenation, and perfusion
• Decreased urine output -gt hypovolemia or reduced
  cardiac output
• Altered mental status may be a sign of
  inadequate cerebral perfusion

4
Stethoscopy

• Precordial or an esophageal stethoscope
• Esophageal temperature ,ECG recording
• -gt atrial arrhythmias, right ventricular
  ischemia, or posterior left ventricular ischemia.

5

• Complications hypoxemia, loss down the
  esophagus, and distortion of surgical anatomy in
  the neck, pharyngeal or esophageal trauma and
  interfere with nasogastric tube
• positioning.

6

• oximeter,
• capnography,
• ECG detect
• untoward incidents more often than the
  stethoscope does .

7
Activated coagulation time (ACT)

• Most widely used perioperative coagulation
  monitor Use Monitor high-dose heparin
  anticoagulation, such as during cardiopulmonary
  bypass surgery. May also be used when an
  immediate measure of heparin anticoagulation is
  required at the bedside, such as with
  extracorporeal membrane oxygenation (ECMO),
  hemodialysis, cardiac catheterization, and
  vascular surgery.
• Simplicity, low cost, and ability to monitor
  anticoagulation- large doses of heparin - for
  cardiac surgical procedures

8

• Shortingcomings
• Insensitivity-low concentration of heparin
• Hypothermia , hemodilution-prolong ACT

9
Heparin management test (HMT)

• Dry reagent chemistry for analysis of coagulation
  
• Rapid, reproducible measure of functional
  anticoagulation in heparin-containing blood
• Cardiac surgery suggests-more accurate and more
  reproducible measure of heparin activity than the
  ACT does
• Hypothermia and hemodilution-improved

10
High-dose thrombin time (HiTT)

• Heparin anticoagulation, primarily during cardiac
  surgery
• High reagent concentrations of thrombin to cleave
  fibrinogen directly and generate a fibrin clot.
• Most surgical procedures requiring heparin
  administration, HiTT prolongation will correlate
  with the heparin anticoagulant effect.

11
Pulmonary Artery catheter

• Swan-Ganz - right heart catheterization

12

• Function
• cardiac output (thermodilution)
• pulmonary arterial pressure,
• Right and left heart filling pressure mixed
• venous oxygen saturation(SVO2)

13
Indication

• Heart failure
• Shock
• Congenital heart disease
• Burns
• Sepsis
• Perioperative high-risk surgery

14
Complications from the technique 

• Invasive
• vascular damage
• hematoma
• infection
• pulmonary thrombosis
• kinking of catheter
• ventricular fibrillation
• complete heart arrest

15
Complications from the catheter

• thrombosis
• bacteremia
• endocarditis
• valve rupture
• pulmonary embolus
• pulmonary artery rupture

16
Two-D echocardiography and Transeophageal Doppler
Monitoring

• Decreased in PAC use in recent years.
• Monitor stoke volumn during anesthesia and
  surgery increasingly.

17
Pulse contour analysis and Transpulmonary
Thermodilution

• cannulate both a large a. and central vein ,
  limited
• Stroke volumn using the pressure tracing obtained
  from a large arterial(femoral) catheter
• Cold injectate is infused into a cental v. and a
  change in T detected in peripheral a.

18
Lithium Dilution Cardiac output

• Small amount of lithium is injected into a
  peripheral v., concentration difference detected
  from a peripheral a.
• Less invasive (only peripheral a. and v.
  cannulation is required) and correlates well with
  thermodilution cardiac output.

19
Transthoracic Biompedance

• The larger the amount of intrathoracic fluid
  volumn , the higher the resistance to the flow
  of the electrical current

20

• CO can then be derived from cyclical changes in
  thoracic bioimpedance.
• Limited to pleural effusion , pulmonary edema ,
  peripheral edema , inability to assess cardiac
  prelord

21
Direct Fick Method

• Gold standard for the measurement of CO.
• COVO2/Cao2-Cvo2
• Indirect Fick Method
• COVco2/Cvco2-Caco2

22
CVP

• Subclavian vein, internal jugular vein, femoral
  vein, etc
• Normal CVP is 2-6 mm Hg.

23

• Central venous pressure monitoring
• Trauma  
• Major surgery
• Rapid infusion of fluids (through large
  cannulas) 
• Prolonged antibiotic therapy (e.g., endocarditis)
• Sampling site for repeated blood testing
• Infusion of hypertonic or irritant solutions
• Transvenous cardiac pacing
• Temporary hemodialysis
• Drug administration  
• Concentrated vasoactive drugs  
• Hyperalimentation  
• Chemotherapy  Drugs
•  Aspiration of air emboli
• Inadequate peripheral intravenous access

24

• Complications
• Pneumothorax
• Infection
• Hemorrhage (bleeding) and formation of a hematoma
  
• Arrhythmia

25

• Contraindications
• Patient who is agitated uncooperative
• Distorted landmarks obesity, deformity of chest
  wall, previous surgery, or facture of clavicle
• Vasculitis coagulopathies

26
ScvO2 v.s SvO2

• ScvO2 mixed venous saturation
• SvO2 is drawn from the pulmonary artery port of a
  ganz and reflects a mixture of venous blood from
  the SVC, IVC and coronary sinus. Normal SvO2 is
  60-80.
• ScvO2 is drawn from a central venous line
  (generally subclavian or jugular). normalgt70
• A reading lt 70 indicates the patient is
  extracting more than normal (indicating that the
  cardiac output alone is not high enough to meet
  tissue oxygen need).

27
Mechenical ventilator

• 1.Pneumonia
• 2.asthma
• 3.COPD
• 4.CHF
• 5.Coma
• 6.Stroke
• 7.GA

28
Complication

• 1.nasosinusitis
• 2.oral ulcer
• 3.vocal cord injury
• 4.granuloma,edema in throat
• 5.dysphagia
• 6.bronchomalachia
• 7.Pneumonia
• 8.high pressure-gtalveolar injury,pneumothorax

29
Continual end-tidal CO2
30

• ER
• ETT position conformation
• CPR quality assessment
• Sedation monitoring
• Ventilation assessment
• ICU
• ETT position conformation
• Circuit integrity confirmation
• Shock status evaluation

31
Neurologic Monitoring

• EEG
• Sensory evoked responses (SERs)
• Electromyogram (EMG).

32

• EEG - surgical or anesthetic-induced reduction
  in blood flow or by retraction on cerebral
  tissue.
• EEG - summation of excitatory and inhibitory
  postsynaptic potentials - pyramidal cells in the
  cerebral cortex.
• EEG may be used to
• predict neurologic
• outcome after a
• brain insult.

33

• sensory evoked responses (SERs)
• Evoked potentials are electrical activity
  generated in response to a sensory or motor
  stimulus.
• Somatosensory (SSEP)
• Auditory (BAEP)
• Visual (VEP) potentials.

34

• Thanks your attention!