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Monitoring in anesthesia and intensive care (Types (Invasive vs. non…

- - - - Oxygenation monitornig
        
        Pulse oximeter: Measures the arterial blood haemoglobin saturation with oxygen and a pulse rate.
        
        ABG vs. pulse-oximetry
         Pulse oximetry does not assess ventilation or acid base status.
         Pulse oximetry becomes unreliable when saturations fall below 70-80%.
         Pulse oximetry cannot interpret methemoglobin or carboxyhemoglobin.
         Pulse oximetry is non-invasive and provides immediate and continuous data.
        
        Capnography
        
        Capnography helps to detect:
        
        esophageal intubation
        
        endotracheal intubation
        
        airway obstruction
        
        circuit leakage
        
        spontaneous breathing (recovery from neuromuscular blockade)
        
        hypoventilation
        
        Signs of ROSC (return of spontaneous circulation) during CPR
        
        End-tidal CO2 analysis:
         Normal value 30-35 mmHg
         Measured by infrared absorption spectrography
    - - Cardiac Monitoring Methods
         Symptoms and signs: eg, angina, diaphoresis, mental state
         Finger on the pulse
         Auscultation
         Electrocardiogram: rate, rhythm, ischemia
         Pulse oximeter waveform: rate, rhythm
         Blood pressure: cuff, oscillotonometry, art. line
         Volume Status: low-tech, high-tech
      - ECG
         Rate
         Rhytm
         Repolarization
         Heart position
         Muscle hypertophy
         Regional ischemia
        
         Typical ECG monitoring: Lead II
         Best for monitoring of arrhthymias
         P wave best visible
        
        Monitoring of ischemia
         Modified V5 detects 89% of ST changes due to left ventricular ischemia
      - Central Venous Pressure
         Requires a catheter in vena cava superior
        
        High readings:
         Ventricular failure (R or L)
         Fluid overload
         SVC obstruction/pressure
         Tricuspid regurgitation
         Pulmonary hypertension
         Tricuspid valve regurgitation
         Pulmonary artery stenosis
        
        Low readings:
         Peripheral vasodilatation
         Hemorrhage
         Hypovolemia
         Sepsis
         Addisonian crisis
         Sympathetic dysfunction
         Regional anesthesia
      - Non-invasive blood pressure (NIBP)
        
        Source of errors:
         Inaccurate cuff size:
         External pressure (surgeon)
         Shivering
         Arrhythmia
         Severe vasoconstriction
        
        Complications:
         Ulnar nerve palsy
         haemorrhage
         Limb oedema
      - Blood pressure monitoring – invasive
        
        Requires a cannula placed inside an artery (radial, ulnar, brachial, femoral, dorsal pedis)
        
        Indications:
        cardiovascular instability
         Direct manipulation of cardiovascular system
         Inability to measure NIBP
         arterial blood sampling
        
        Contraindications:
         Local infection
         Impaired blood circulation
        
        Complications:
         Direct trauma – a-v fistula, aneurysm
         Hematoma
         Infection – local and/or general
         Thrombosis
         Embolization
         Hemorrhage
      - Cardiac Output
        
         Catheterization of pulmonary artery
         Sonography + Doppler
         Fick principle
         Bioimpedancy
         Pulse contour analysis
        
        CI – Cardiac Index
        PCCI – Pulse Contour Cardiac Index
        SVI – Stroke Volume Index
        • Cardiac Index is Heart Rate x Stroke Volume Index
        • Stroke Volume depends on preload, afterload and contractility
        • Cardiac Index is indexed to the Body Surface Area (BSA)
      - Esophageal Doppler Monitoring
        
        VIRTUES
        • CO/CI – continuous, dynamic measurement
        • No need for catheterization
        • Heart chambers pressures measurement
        • MINIMAL CHANCES OF COMPLICATIONS
        
        FLAWS
         Measurement depending on patient’s position
         Stability of probe is essential–SEDATION
         Children?
         EXPERIENCE
      - Preload Volume:
        Blood volume which fills the heart just prior to beating
        
        GEDI – Global End-diastolic Volume Index
      - Afterload: Resistance against which the heart must overcome to eject blood
        
        SVRI - Systemic Vascular Resistance Index
        • Depends on the degree of vasoconstriction
        • Increased:
        Centralization, Vasopressor therapy, Cardiogenic shock
        • Decreased:
        Septic shock, Anaphylactic shock
      - Contractility - Performance of the heart muscle
        
        GEF* – Global Ejection Fraction
        
        CFI* – Cardiac Function Index
        
        dPmx – Left Ventricular (LV) contractility
      - Differentiate between types of pulmonary edema
        
        PVPI* – Pulmonary Vascular Permeability Index
        • Provides a differentiated view of pulmonary edema:
        • cardiac
        • osmotic
    - -  Clinical Signs: eye signs, respiratory signs, cardiovascular signs, CNS signs
        
        EEG monitoring
        
        Facial EMG monitoring
        
        esophageal contractility