Beginner’s Guide

Beginner’s Guide
Foreword

Dear Reader,

This Beginner’s Guide has been made for you, who have recently joined the sales, market-
ing, technical or administrative team of your country. As you may not be very familiar with
Datex-Ohmeda, we would like to provide you this tool for understanding the basics behind
our business. This book will give you information about the customer environment, basic
anatomy and physiology, and the different monitoring parameters.

This book will help you to understand

1 the patient care processes and the basic function of the five care areas, emergency,
anesthesia, post-anesthesia, critical care and patient transportation
1 the basic physiology of breathing, blood circulation and brain function
1 the clinical monitoring parameters of patient’s vital functions
1 the importance of monitoring and taking care of patient’s vital functions

Hopefully this Beginner’s Guide will help you to understand the needs of your
customer even better.

Yours truly,

Timo Koskinen
Director of Human Resources
Datex-Ohmeda Division
Instrumentarium Corporation
CONTENTS

1 PATIENT CARE ................................................................................................................................. 1

1.1 Emergency .............................................................................................................................. 1

1.2 Anesthesia ............................................................................................................................. 3

1.2.1 Types of Anesthesia .................................................................................................... 4
1.2.2 Historical Review ....................................................................................................... 5
1.2.3 Patient Flow ................................................................................................................. 5
1.2.4 Physical Environment ................................................................................................ 6
1.2.5 Anesthesia Machine .................................................................................................. 7
1.2.6 Care Providers in the Operating Room .................................................................. 9
1.2.7 Preoperative Care ..................................................................................................... 10
1.2.8 Intraoperative Care .................................................................................................. 11
1.2.9 Postoperative Care.................................................................................................... 13
1.2.10 Information Management and Documentation ................................................ 13

1.3 Critical Care ........................................................................................................................ 15

1.3.1 Physical Environment .............................................................................................. 16
1.3.2 Care Providers in the ICU ....................................................................................... 16
1.3.3 Patient Admission ..................................................................................................... 17
1.3.4 Patient Care ............................................................................................................... 18
1.3.5 Rehabilitation and Discharge ................................................................................. 18
1.3.6 Ethical Considerations ............................................................................................ 19

1.4 Transport .............................................................................................................................. 20

1.4.1 Principles of Safe Transfer ...................................................................................... 21
1.4.2 Modes of Transfer and Associated Risks ............................................................. 21

2 BASIC PHYSIOLOGY .................................................................................................................... 23

2.1 Breathing.............................................................................................................................. 23
2.1.1 The Respiratory Organs ........................................................................................... 24
2.1.2 Mechanics of Breathing .......................................................................................... 25
2.1.3 Regulation of Breathing ........................................................................................... 26
2.1.4 Problems Associated with Breathing .................................................................... 27
2.1.5 Assisting a Patient’s Breathing ............................................................................... 29

2.2 Heart and Blood Circulation ............................................................................................ 33

2.2.1 Anatomy of the Heart .............................................................................................. 35
2.2.2 Electrical Activity of the Heart .............................................................................. 36
2.2.3 Functioning of the Heart ......................................................................................... 38
2.2.4 The Components of Oxygen Delivery .................................................................. 39
 2.3 Metabolism .......................................................................................................................... 42

2.4 Nervous System .................................................................................................................. 44

2.4.1 Brain Anatomy .......................................................................................................... 46
2.4.2 Peripheral Nervous System .................................................................................... 47
2.4.3 Neurons and Signal Transmission ........................................................................ 48
2.4.4 Factors Affecting Nervous Function ..................................................................... 48
2.4.5 Regulation of Body Temperature ........................................................................... 48

3 PATIENT MONITORING .............................................................................................................. 50

3.1 Monitoring Ventilation ...................................................................................................... 51
3.1.1 Spirometry .................................................................................................................. 51
3.1.2 Carbon Dioxide ......................................................................................................... 54

3.2 Monitoring Oxygenation ................................................................................................... 56

3.2.1 Patient Oxygen .......................................................................................................... 56
3.2.2 Pulse Oximetry.......................................................................................................... 57
3.2.3 Mixed Venous Oxygen Saturation ......................................................................... 58

3.3 Monitoring Metabolism by Gas Exchange .................................................................... 59

3.4 Monitoring Blood Circulation.......................................................................................... 61

3.4.1 Blood Pressures ......................................................................................................... 61
3.4.2 Cardiac Output .......................................................................................................... 63
3.4.3 Gastric Perfusion ...................................................................................................... 63

3.5 Monitoring Electrocardiography..................................................................................... 65

3.6 Monitoring EEG .................................................................................................................. 68

3.7 Monitoring Adequasy of Anesthesia .............................................................................. 70

3.7.1 Inhalational Anesthetic Agents .............................................................................. 71
3.7.2 Muscle Relaxation .................................................................................................... 72
3.7.3 Depth of Anesthesia and Sedation........................................................................ 73

3.8 Monitoring Temperature .................................................................................................. 76

4 ANSWERS TO THE TASKS ......................................................................................................... 77

1 PATIENT CARE
Learning objectives:
After studying this chapter you will
1 have an overview of patient flow in the hospital
within the five care areas, emergency, anesthesia,
post-anesthesia, critical care and transportation
1 understand the characteristics of the five care
areas
1 understand how patient care varies according to a
patient’s medical condition and therapy
1 understand the specific challenges the care
providers face in all five care areas
1.1 Emergency
When a sudden, serious medical crisis or a natural
disaster that threatens the life of a person or a group
of people occurs, it is called an emergency.
Emergencies also exist when an individual’s
psychological or physiological integrity is impaired.
To meet these sudden needs, hospitals have
Hospitals around the world vary in size from
small clinics to huge hospitals. They are either
privately owned, owned by community, or by state.
There are veteran hospitals and children’s hospitals.
There are hospitals for acutely ill, and for the dying.
People come to the hospital looking for cure to
their illness. The ultimate goal of every hospital is to
improve patients’ condition, or if that is not possible,
to ease their suffering.
developed specialized departments in which to care
for people with the aforementioned crises.
Emergency Unit, Emergency Department (ED),
Emergency Room, Trauma Unit, and Casualty Unit
may all be synonyms of places where emergency
care is given in a hospital.
B e gi n n er ’s G ui de 1
 The staff in the emergency department consists
of physicians, physician’s assistants, nurses, and
ancillary staff. The emergency department is also
supported by all other professional services in the
hospital. For example, members of the radiology,
laboratory, respiratory therapy, or social service
teams can be involved in the client’s care, as well.
Emergency units regularly receive clients with
a wide range of needs. Since there is generally no
pre-knowledge of the incoming client’s condition or
history, nurses in the emergency unit are taught
triage skills to assist in evaluating the severity of a
client’s needs. Triage, meaning ‘to sort’, was
developed during the World War I as a means of
quickly and accurately assessing the urgency of
care, the best place for care, and the prioritization of
care. Today, clients are assessed as soon as they
enter the department using the triage method.
While most clients arrive to the emergency unit
in crisis and soon leave, approximately 20% of those
entering the emergency department have a life-
threatening problem. These urgent cases are
expediently cared for, while those cases deemed as
non-urgent may have to wait for long periods of
time. One of the most common complaints of people
in the emergency room is that the wait was too long.
Often, the emergency unit is the first contact
the public has with the hospital, and a generalization
of the hospital is based on the treatment received in
the emergency unit.
Continual monitoring is indicated as a
diagnostic aid in caring for symptomatic clients. For
example, in the event of a trauma client, the need
for rapid assessment, diagnosis, and intervention is
acute. Often, intra-venous and intra-arterial
catheters, tubes, and drains are inserted, various
types of monitoring are commenced, laboratory
specimens are taken, medication and fluid infusions
are started, and physical examinations are made
simultaneously. During the entire care process,
accurate documentation related to the client must
be maintained.
The nature of the emergency department is
highly unpredictable. With an increasing number of
annual patient visits and higher patient acuity levels,
the challenges for the emergency care professional
have grown. Often, multiple tasks are being handled
at the same time, and while some clients are
entering the department, others are being
discharged to other departments, other hospitals, or
home. The work pace is fast and the staff burn out
rate is high.
Yet, it is the variability, fast pace and the
expecting the unexpected that gives the ED staff the
strength and willingness to keep going. To be able to
save lives and ease the suffering of the patients gives
joy and satisfaction.

TASKS 1.1 Emergency

Q1 What is an emergency? ____________________________________________________________________
_________________________________________________________________________________________

Q2 Triage means _____________________________________________________________________________

_________________________________________________________________________________________

Q3 How many of the ED patients have a life threatening problem? __________________________________

_________________________________________________________________________________________

Q4 How would you describe the nature of the ED? _______________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________

2 Be g i nne r ’s Gu i d e
1.2 Anesthesia
The word anesthesia originates from the Greek
word anaisthesis meaning ‘no sensation’. Anesthesia
means the loss of sensation during an operation or a
treatment. Depending on the type of procedure,
consciousness, memory, and muscle activity may be
absent, as well.
Analgesia
Picture 1. The goals of anesthesia.
The goal of anesthesia is to ensure the patient a
safe, painless operation (picture 1). For the surgeon
the anesthesia provides optimal conditions for the
procedure. Anesthesia enables procedures to be
performed without pain, comfortably and safely.
Relaxation
Unconsciousness
B e gi n n er ’s G ui de 3
1.2.1 Types of Anesthesia
There are three different types of anesthesia: local,
regional and general (picture 2). The anesthesia
Local Regional
Picture 2. Different types of anesthesia.
1. Local anesthesia means numbing a small area by
applying the numbing medicine directly to the area
of the body which is going to be operated, e.g. for
the removal of a mole.
2. Regional anesthesia is produced by applying the
local anesthetic to nerves innervating a certain
region of the body and numbing the whole
innervated area e.g. for operating on a knee or an
elbow. Local anesthetics can be applied to spinal
cord either to spinal or epidural space to numb the
legs or the abdominal (stomach) area.
Local and regional anesthesia provide
numbness, pain relief (analgesia), and some degree
of immobility (muscle relaxation) in the
anesthetized region of the body.
3. Administering anesthetic medication causing
sleep, pain relief, and relaxation produces general
anesthesia. Medication can be administered into a
peripheral vein (intravenously) or by letting the
patient to breathe in (inhale) a gas mixture
containing vapor of a volatile anesthetic agent
(halothane, enflurane, isoflurane, sevoflurane, or
desflurane). General anesthesia produced only with
intravenous anesthetics is called total intravenous
anesthesia (TIVA).
4 Be g i nne r ’s Gu i d e
method is selected according to the surgical needs,
the condition and the wishes of the patient.
General
The goal of general anesthesia is to produce
1 Unconsciousness (hypnosis)
1 Pain relief (analgesia),
1 Lack of memory of surgical experience (amnesia),
1 Immobility (muscle relaxation)
1 Autonomic nervous system stability
General anesthesia is needed when it is
beneficial for both the patient and the surgical
procedure to be performed that the patient is
unconscious and relaxed during the operation. For
example, operations performed in stomach, chest or
head area or surgery involving major blood vessels
require general anesthesia.
The whole process of having a surgical
procedure done is called a perioperative process. It
consists of preoperative, intraoperative and
postoperative phases. The preoperative phase
begins when the decision to operate is made. It
covers all actions and preparations done before the
operation. The intraoperative phase means the time
during the operation and the postoperative phase
starts at the end of the operation and lasts until the
patient is discharged from the hospital.
1.2.2 Historical Review

Several discoveries, starting from the late 1700s, have contributed to the evolution of anesthesia (Table 1).

Discovery of oxygen 1770

Nitrous oxide as “laughing gas” for pain relief 1808
Discovery of morphine early 1800s
Use of ether & cloroform for pain relief early 1800s
First general anesthesia with ether 1846
Hollow metal needle for injecting morphine into painful area 1853
Oxygen – Nitrous oxide mixture 1870
First spinal anesthesia 1885
First elective oral intubation 1878
Main blood groups: transfusion of blood becomes safer early 1900s
Asepsis = prevention of contacts with micro-organisms early 1900s
Carbon dioxide absorber allowed the use of closed circuit anesthesia 1915
First intravenous anesthesia 1934
Neuromuscular blocking agents (curare) 1942
Manually controlled breathing 1940s
Copper Kettle vaporizers 1950s
Iron lung ventilators 1952
Arterial blood gas analysis 1955
Modern inhaled anesthetics
Halothane 1956
Enflurane 1973
Isoflurane 1985
Sevoflurane 1986
Desflurane 1990

Table 1. Discoveries related to anesthesia.

The first general anesthesia was performed in 1846
in Boston. Doctor William T.G. Morton used ether to
anesthetize his patient.
Anesthesiology has been a separate medical
specialty since the early 1900’s. The American
Society of Anesthesiologists (ASA), founded in 1938,
has provided extensive resource material regarding
the practice management of anesthesia. For
example, the ASA preoperative patient classification
invented by the society, is widely used today.

1.2.3 Patient Flow

The surgical procedure may be elective i.e. planned
or an emergency case, requiring surgical actions.
Elective surgery will be planned after a surgical
disease has been diagnosed. The elective operation
can be performed as a day surgery case or as an
inpatient surgery case.
Day Surgery
Patients undergoing day surgery also called
ambulatory or outpatient surgery, are arriving and
leaving the hospital on the day of operation. Such
surgical procedures which cause minimal
postoperative physiological impairment and have
uncomplicated recovery are suitable for day surgery.
Less invasive surgical techniques, such as various
types of scopic procedures, have made it possible to
increase the proportion of the cost effective day
surgery. Today, more than 60% of all elective surgery
is performed in outpatient surgical settings.

B e gi n n er ’s G ui de 5
Inpatient Surgery
Patients undergoing major invasive procedures, or
procedures that are likely to have postoperative
complications, should be admitted to the hospital at
least a day before the operation and stay at least one
night after the surgery (inpatient surgery).
Patients who have had major surgery, like open
Outpatient
Home admitting
Ward In du
ED/ICU
1.2.4 Physical Environment
Operating departments are usually situated near the
emergency department and critical care units so the
transfer of critically ill patients is as fast and easy as
possible. Traffic to the operating departments is
restricted because of the need to keep the area as
clean as possible.
In surgical procedures the patient’s skin is
usually cut open. This surgical incision breaks the
natural protection barrier (the skin) of the body. It
makes patient vulnerable to any microorganism to
enter his body. That is why the operation must be
done with sterile technique in a very clean setting.
There are four different cleanliness zones
inside the operating department. The area of the
actual operation is kept clean from all living micro-
organisms (sterile). The next cleanest area is the
operating room, where the operation is going on. All
other patient care areas outside the operating room
belong to the third zone. The fourth zone contains
of the offices and other non-patient care areas.
All material used in OR has to be easily
cleaned and disinfected or disposable, including the
surfaces of walls, lamps, operating tables, and
monitors.
Equipment
There is plenty of equipment in an operating room.
6 Be g i nne r ’s Gu i d e
heart or neurosurgery, require intense postoperative
care and are often transported to a special intensive
care unit for postoperative care. Emergency patients
are always staying in the hospital at least 1 – 2 days
postoperatively and thus belong in inpatient surgery
group (picture 3).
Home
PACU
on
c ti Ward
OR
SICU
Picture 3. Patient flow in surgery.
Surgical equipment consist of the operating table,
lamps, surgical suction units, electrocautery
machine, tables with the instruments, and different
waste collectors. There also may be an x-ray
machine for either still pictures (e.g. checking
alignment in orthopedic surgery) or continuous
transillumination which is necessary for example
during the insertion of the pacemaker electrodes
into patient’s heart.
For anesthesia, each operating room must have
an anesthesia machine for oxygen and anesthetic
agent delivery, and managing patient ventilation.
Anesthesia monitor(s), suction unit for suctioning
secretions from the airway, infusion pumps and
perfusors are also necessary. There is an anesthesia
table containing accessories needed for anesthesia
delivery like needles, syringes, cannulas, intubation
equipment, and anesthetic drugs.
Day Surgery Facilities
Day surgery and general surgery have usually
separate facilities because their needs differ a lot.
Ambulatory surgical facilities need to be well
designed in order to ensure optimal delivery of
surgical services at reduced cost. They need a
special registration area, where the patient arrives
first. From there the patient is taken via changing
rooms to the preoperative holding area to wait for
the operation.
Recovery from ambulatory surgery is divided
in three different phases. For the immediate
postoperative recovery the patient is transported to
the first phase recovery room. In the second phase
recovery room the patient can stand up, eat, and
1.2.5 Anesthesia Machine
The anesthesia machine has two functions: it mixes
gases together (gas machine) and generates positive
pressure to push the mixture into the patient’s lungs
(ventilator). Components of the anesthesia machine
are (picture 4):
1 2
30% Vaporizer
O2 AA
3
Air/
N2O
70%
4
Ventilator
control
unit
Picture 4. Components of an anesthesia machine.
Gas Delivery System
The gas delivered by an anesthesia gas delivery unit
is a mixture of oxygen (O2), nitrous oxide (N2O) or
air, and anesthetic agents. Nitrous oxide is a weak
gaseous anesthetic which is traditionally used with
oxygen. N2O potentiates the effects of other
anesthetic agents which then are needed in lower
concentrations. N2O has very few side effects.
Inhalational anesthetic agents are volatile
(evaporate rapidly) and are administered by leading
the gas vapor from a vaporizer into the breathing
circuit. Known volatile anesthetic agents are
halothane, enflurane, isoflurane, sevoflurane, and
drink before leaving the hospital. The third phase
recovery stands for the time after discharge from
the hospital and refers to resumption of normal
daily activities at home. All ambulatory surgical
clinics have guidelines for discharging the patient.
When these guidelines for safe discharge are
fulfilled the patient may go home.
1 flowmeters for adjustment of O2, N2O and air flows
2 anesthetic agent vaporizers
3 breathing system with
4 overflow valve for scavenging (evacuation)
5 ventilator
5
desflurane. They vary some in their effects and side-
effects in the patient.
Oxygen is usually administered during
anesthesia as a 30% concentration together with
70% nitrous oxide or air. Volatile anesthetic agents
are vaporized into the gas mixture when an
adjusted volume of the gas flow is directed through
the vaporizer. This final mixture is called a fresh
gas.
The fresh gas is fed through the fresh gas outlet
(FGO) into the patient circuit which is an interface
between the patient and the anesthesia machine.
B e gi n n er ’s G ui de 7
The Patient Circuit
The breathing system is a pathway for the gas
mixture to enter the patient (inspiratory limb) as
well as one for the exhaled gas mixture to lead away
from the patient (expiratory limb). Unidirectional
Vaporizer
30% AA
O2
Air/
70%
N2O
Picture 5. Non-rebreathing system.
Breathing systems can be divided by their
function into rebreathing and non-rebreathing
systems. In the non-rebreathing system (picture 5),
gases expired by the patient are directed straight to
the gas scavenging system which exhausts them out
from the operating room. In the rebreathing system
Vaporizer
O2 30% AA
Air/
70%
N2O
Picture 6. Rebreathing system.
Rebreathing systems with CO2 absorption
become non-rebreathing systems when fresh gas
flow exceeds patient’s minute volume. For the
patient it doesn’t matter where the gas comes from
as long as the mixture, temperature and humidity
are correct. But recirculation of gases makes it
possible to lower fresh gas consumption.
When fresh gas flow is reduced it is called a
8 Be g i nne r ’s Gu i d e
valves (one in each limb) control the flow direction
of the gas inside the breathing system (or patient
circuit). Each breathing system has a specific
volume.
Manual ventilation bag
or ventilator
Scaven-
ging
(picture 6), part of the expired gases is directed back
to the patient. Rebreathing systems may be without
a CO2 absorption unit (e.g. Jackson-Rees) or with a
CO2 absorber (e.g. Datex-Ohmeda anesthesia
machines).
CO
42
Manual
ventilation
bag or
ventilator
low flow anesthesia and with extremely low flows,
a minimal flow anesthesia. Low flow anesthesia
enables considerable savings in anesthetic agents
and gas consumption. It is also beneficial for the
patient, as re-breathed gas is warm and moist.
Oxygen and anesthetic agent monitoring is
necessary in minimal and low flow anesthesia, so
that adequate oxygenation of the patient can be
guaranteed and sufficient level of anesthesia
maintained. Monitoring of inspiratory and
expiratory concentrations of oxygen, N2O, and
volatile anesthetics supervises adequate fresh gas
delivery during anesthesia.
Anesthesia Ventilator
The ventilator is something that generates the
positive pressure needed for the gas to enter the
lungs. It can be the anesthetist’s hands squeezing a
“bag” (manual ventilation), or it can be a
pneumatically driven bellow (“bag-in-bottle”) or a
mechanically driven piston. In the case of manual
ventilation an adjustable overflow valve is needed to
adjust the “tightness” of the circuit.
Modern anesthesia ventilators are typically
time-cycled and powered by electricity and
compressed gas which serve as a ventilator driving
gas between the bag and the bottle (picture 7). The
driving gas is air or oxygen.
1. 2. 3. 4.
1.2.6 Care Providers in the Operating Room
An anesthesiologist is responsible for the
anesthesia function. He may take care of patients,
supervise the care or delegate responsibilities of
anesthesia delivery. Anesthesiologists also provide
consultation services throughout the hospital. They
may take care of treating and managing chronic
pain, and long term intravenous nutrition.
Nurse anesthetist stays with the patient from
the moment he arrives to OR until the time he is
taken to the recovery room. Differing from country
to country, nurse anesthetists can either assist the
anesthesiologist in anesthesia delivery, or are fully
responsible for the anesthesia delivery. The nurse
takes care of patient’s safety, monitors him
throughout the procedure, and medicates him as
necessary.
Anesthesia Ventilation
During anesthesia, the patient can breathe
spontaneously, his ventilation can be manually
assisted by squeezing a breathing bag, or his
ventilation can be mechanically controlled by
ventilator bellows. During general anesthesia all
these modes are used.
The type of ventilation used depends on the
type of operation, type of anesthesia, and the age
and condition of the patient. The patient can
breathe spontaneously during local or regional
anesthesia, but when general anesthesia is
administered with muscle relaxation, the patient
ventilation has to be controlled.
Monitoring of Fresh Gas Delivery
Monitoring of inspiratory and expiratory gas
concentrations of oxygen, nitrous oxide, and
anesthetic agents guides fresh gas delivery during
anesthesia. The lower the amount of fresh gases
used, the more important the gas monitoring is ,
since the rebreathed gases dilute the fresh gas
concentrations from the anesthesia machine.
Picture 7. “Bag-in-bottle” ventilator principle: during
inspiration the driving gas passes into the bellows chamber,
squeezes the bellows, and pushes the gas inside the bellows
into the breathing system (1 and 2). During expiration the
driving gas is vented into room air (3) and the bellows is filled
with expiratory gas as the patient exhales (4).
Besides the anesthesia team, there are plenty
of personnel in the operating room taking care of
the patient: surgeons or other physicians
performing the procedure, nurses assisting them,
different technicians (e.g. respiratory, perfusion or
orthopedic) and other assisting personnel.
The scrub nurse is responsible for preparing
the entire surgical area. This includes collecting all
the necessary instruments on the sterile tables,
cleaning the patient’s skin, and covering the patient
with sterile drapes. She also assists the surgeon
during the operation. The circulating nurse assists
the surgical team by bringing extra equipment,
laboratory tests, results etc. in and out from the
operating room.
B e gi n n er ’s G ui de 9
1.2.7 Preoperative Care
Preoperative assessment
Any surgical procedure or anesthetic condition
poses a risk to the patient. Therefore, the anesthetist
performs the pre-operative assessment to estimate
the risks of surgery and anesthesia, and balances
them against the benefits of the proposed operation.
The patient’s health history is reviewed and a
physical examination is done.
The patient’s general condition, background
diseases, current medication, and general
anatomical, physiological, and mental status are
checked. Laboratory tests and X-ray /computer
tomography (CT) / Magnetic Resonance Imaging
(MRI) diagnostics provide the anesthetist with
additional information to help plan the anesthesia.
It is also necessary to make sure that the patient is
able to function at home after being released from
the hospital.
The anesthetist is responsible for determining
the medical status of the patient, developing a plan
for anesthesia care, and acquainting the patient, or
responsible adult, with the proposed plan.
American Society of Anesthesiologists has
developed the ASA physical status classification
which clinicians use around the world to
preoperatively assess the patient’s physical risks of
surgery (Table 2). The anesthetist will select the
anesthesia method based on the patient’s status and
risk assessment, as well as on discussions with the
surgeon(s).

ASA 1 A normally healthy patient

ASA 2 A patient with mild systemic disease (e.g. hypertension)

ASA 3 A patient with severe systemic disease (e.g. diabetes and hypertension)

ASA 4 Severe systemic disease which is a constant threat to life (e.g. uncontrolled diabetes and unstable angina)

ASA 5 A patient who is not expected to survive 24 hours without the operation

ASA (1-5)E Signifies that the operation is to be performed as an emergency. This places the patient in the next risk level

Table 2. American Society of Anesthesiologists’ ASA- classification

Preoperative Preparation
All preparations done before surgery are made to
protect the patient from any possible harm. Patient
preparation for surgery includes informing him
about the whole process, checking the skin in the
operated area for possible infections, and having the
patient take a shower or bath. Patient may not eat or
drink anything for a few hours prior to surgery to
prevent regurgitation of gastric contents and
aspiration while under anesthesia.
The patient may receive premedication. Its
purpose is to relax the patient, lessen the anxiety,
and to protect him from possible complications of
anesthesia by decreasing secretion of saliva and
gastric acids, speeding up the heartbeat, etc.
In emergency operations, the anesthetic risk is
markedly increased because the patient has not
been fasting and preoperative assessment and
preparations are limited.
The nurse anesthetist, anesthesia technician,
or the anesthetist carefully checks the functions of
all operating room equipment before the patient is
brought in. Monitoring equipment necessary for the
patient is decided from the available preoperative
information.
One purpose of anesthesia is to keep the
patient’s vital functions stable during the operation
or procedure. It means that the patient’s
hemodynamic condition, oxygenation and
ventilation as well as the fluid balance have to be
carefully monitored. Also, it is important to follow
the depth of anesthesia.
In many countries there are so-called

10 Be g i nne r ’s Gu i d e
minimum monitoring standards which define the
parameters that have to be monitored. They can be
for example
1 ECG (electrical activity of the heart)
1 SpO2 ( oxygen saturation of a peripheral artery)
1 Blood pressure (at least non-invasive)
1.2.8 Intraoperative Care
Induction
Induction of anesthesia is the beginning of the
anesthetic procedure. It is usually preceded by the
placement of a venous catheter for injecting fluids,
anesthetics, and emergency drugs. The normal site
for cannulation is a peripheral vein of the hand or
arm. Sometimes, when the peripheral veins cannot
be accessed, a more central vein, such as the jugular
vein in the neck, may be used.
The goal of induction is to put the patient to
sleep. This can be done by using an inhalational or
intravenous anesthetic. Intravenous induction is
more typical in adults, whereas induction by
inhaling anesthetic agents by facemask is commonly
used in children. The induction agents anesthetize
the patient rapidly.
During induction, administration of
intravenous analgesics (for pain removal) and
neuromuscular blocking agents (NMBA’s) typically
begins simultaneously with anesthetics. NMBA’s
facilitate tracheal intubation and further muscle
relaxation in thoracic, abdominal and certain other
1 Carbon dioxide (CO2)
1 Inspiratory oxygen (FiO2)
1 Temperature
Also, the concentrations of inhalation agents,
and the level of muscle relaxation are monitored
routinely in most cases.
kinds of surgery. Adverse side effects of induction
agents may include respiratory depression and
decreased blood pressure.
Surgical Preparation
Surgical preparation starts after patient is asleep
and connected to the ventilator. Surgical
preparations include positioning of the patient for
the procedure, cleaning the operative area, and
covering the area with sterile drapes.
The entire surgical area must be absolutely
sterile. All areas which are not sterile, must be
covered with sterile drapes. The surgical team is
dressed sterile, and their mouth and nose are
covered with a mask which prevents the
microorganisms of the exhaled air from entering the
surgical area.
Maintenance of Anesthesia
The goals of the maintenance phase of anesthesia
are to keep the patient unconscious, oblivious, free
B e gi n n er ’s G ui de 11
from pain, immobile, hemodynamically stable, and screen. Changes in patient’s condition are treated
well oxygenated. This is done by observing the accordingly with appropriate action, and medication
patient, the surgical site, and by following the (table 3).
monitoring parameters shown on the monitor

Anesthetics for unconsciousness (hypnosis) Inhalational anesthetics

Intravenous anesthetics
- Thiopental
- Propofol
- Etomidate
- Benzodiazepines
- Ketamine
Analgesics for pain - Fentanyl
- Alfentanil
- Sufentanil
- Remifentanil

Neuromuscular blocking agents for muscle relaxation - (Succinylcholine)

- Atracurium
- Rocuronium
- Pancuronium
- Vecuronium
- Mivacurium

Table 3. Anesthesia can be maintained with three groups of medicines. Here are some examples of them.

Of all the phases of anesthesia, the
maintenance phase is the most stable, but still
requires constant alertness. High quality monitoring
of the parameters related to ventilation, circulation,
oxygenation and the anesthetic effect allows fast
response to undesirable changes.
Emergence from Anesthesia
Emergence and recovery from anesthesia should be
predictable and carefully controlled. At the end of
the surgical procedure, the administration of
anesthetic agents is stopped. The medications either
start washing out of the body with every expiration
(the volatile agents), or become metabolized (iv
medications).
Patient’s muscle strength has to return to
normal, and the effect of muscle relaxants must
disappear in order for the patient to be able to
spontaneously breathe again. Reversal agents can be
used to counteract (antagonize) the effects of
relaxants if relaxation remains too deep.
Oxygenation of the patient with higher
concentration of O2 during this phase is advisable to
prevent a diminished amount of oxygen in the
arterial blood (hypoxemia) as the anesthetic agents
are washed out. Monitoring of the expiratory
concentrations of anesthetic agents helps to predict
the moment of emergence from anesthesia.
The goal is to restore spontaneous breathing
and consciousness while still maintaining the
balance of the vital functions. Extubation, taking out
the endotracheal tube, can take place once the
patient is able to breathe spontaneously.

12 Be g i nne r ’s Gu i d e
1.2.9 Postoperative Care
While recovering from anesthesia the patient still
needs to be monitored continuously. Many
anesthesia-related complications occur during the
recovery period. Restoration of breathing may be
delayed due to respiratory depression caused by
anesthetics, analgesics, and relaxants. The surgical
site may start bleeding. The patient may become
nauseous and start vomiting while still groggy.
Possible hypothermia with consequent shivering of
the muscles may also lengthen the recovery time.
According to international studies, the
transportation of the patient from the operating
1.2.10 Information Management and Documentation
Documentation and reporting of all the phases of
the patient process is mandatory. The patient’s
preoperative history and everything what is done
before, during, and after the surgical procedure has
to be precisely documented, so that if questions
arise later on, the documents can be studied. Good
documentation is also important for the safety of the
patient and the continuity of his care. No
information about his condition and given
treatments should be lost during his perioperative
care process.
The reporting of the patient’s condition from
one physician/nurse to the next one taking the
responsibility of patient’s care is very important.
room to the recovery room represents a major risk.
The monitoring of the patient’s vital functions is
very important, but often neglected during this
phase.
After the surgical procedure and when
emergence from anesthesia is in progress, the
patient is most often transported from the operating
theatre to a separate area called Recovery Room or
Post-Anesthesia Care Unit (PACU). There, the
patient is carefully monitored until it is safe for him
to be transferred out.
The names of the responsible staff have to be
documented in the patient documents as well.
Most of the information about patient care in
OR is in some kind of electrical form, like all the
monitoring data, medications given via anesthesia
machine or infusion pumps, and the ventilator
settings. All this data together with a lot of other
data can be collected into a computerized
information management system. The data can be
processed, analyzed, stored, and reused, if
necessary. Different reports can be made, the quality
of care followed up, and the costs managed with this
data.
B e gi n n er ’s G ui de 13
TASKS 1.2 Anesthesia
Q1 What are the goals of anesthesia? Write the name of the symbol under each picture.

___________________________ ____________________________ _____________________________

Q2 Name the three different types of anesthesia __________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Q3 The beginning of the anesthetic procedure is called ____________________________________________

Q4 During preoxygenation the monitoring of ___________________ and ___________________ help to

determine the adequacy of oxygen reserves and thus the correct time for intubation

Q5 The gas delivered by an anesthesia delivery system (with ventilator) is a mixture of ________________ ,
___________________, and ___________________

Q6 The purpose of premedication is to ___________________________________________________________

Q7 The inhalational anesthetics are ____________________, ___________________, ____________________,

___________________, and ___________________

Q8 The standard equipment used to deliver anaesthesia is __________________________________________

Q9 The two extreme kinds of patient circuit are: __________________________ and ____________________

14 Be g i nne r ’s Gu i d e
1.3 Critical Care
Intensive care as a medical discipline is one of the
newest areas in medicine. It is said to have started
from the polio epidemic in Scandinavia in the early
1950s. Physicians learned to keep patients alive with
the help of a ventilator which had earlier been used
for anesthesia.
In the 1970’s, physicians J. Swan and W. Ganz
developed a balloon tipped pulmonary artery
catheter which became one of the cornerstones in
monitoring patients in the intensive care unit.
The goal of critical care is to maintain vital organ function and preserve life while treating
underlying disease.
There are many highly sophisticated types of
technologies involved in the care of critically ill
patients. The term “intensive” care refers both to the
severity of the patient’s illness and the level of care
given. In recent years a high degree of specialization
and a deeper understanding of the needs of
Newer techniques are being developed rapidly.
Critical care is one of the fastest developing
specialties in a hospital.
Critical care means advanced and highly
specialized care provided to medical or surgical
patients whose conditions are life threatening (but
not incurable) and require comprehensive care and
constant monitoring. Care is usually administered in
specially equipped units of a health care facility.
particular patients have given rise to the
development of specialized care areas.
Terminology
Patients requiring intensive care may be found in
many areas of the hospital. They may be treated in
B e gi n n er ’s G ui de 15
an Emergency Department, a Recovery Room, a
Critical Care Unit, or a Step-down Unit. The term
“intensive care” is being replaced with the phrase
“critical care”. Critical care units are most often
named by what type of patients are taken care of in
them:
ICU = intensive care unit
ITU = intensive therapy unit
CCU = coronary care unit, for cardiac
patients
MICU = medical intensive care unit, for
medically ill patients
SICU = surgical intensive care unit, for post-
operative care after major surgeries
1.3.1 Physical Environment
The ideal intensive care unit would be like a
miniature hospital within the hospital, with its very
own services and facilities close by. The essential
services like operating room, radiology department,
laboratories, pharmacy, blood bank, and technical
services should be located near by.
When designing a critical care unit, there are
several things to consider. There must be enough
space for the caretakers and all kinds of medical
equipment around the patient. Nurses must be able
to see the patient at all times. Some patients need to
be isolated from others. Still, patients should have
privacy and somewhat normal sensory surroundings
1.3.2 Care Providers in the ICU
Intensive care units are directed mostly by a
physician and/or a nurse manager. There are also
several consulting physicians involved in patient
care.
Originally, many ICU physicians were
anesthetists, and in many parts of the world they
still are. In some countries, intensive care medicine
is a medical specialty. However, the physicians
working in intensive care generally come from
another area of expertise, such as pulmonology,
surgery, cardiology, or anesthesia.
Whatever the educational specialty, the
16 Be g i nne r ’s Gu i d e
Neuro ICU = intensive care unit for neurological
patients
Trauma Unit = intensive care unit for trauma
patients
AICU = adult intensive care unit
PICU = pediatric intensive care unit, for
children
NICU = neonatal intensive care unit, for
newborn babies
In High Dependency/High Care/Medium Care/
Intermediate Care/Step-down Unit patients require
less intensive care than ICU patients do, yet more
than is provided on a regular ward.
to prevent disorientation and confusion. The
physical design of the unit has an effect on cross
infection between patients, patient’s safety, sensory
overload, distress, privacy, staff communication, and
visual monitoring.
There is a huge need for storage space in every
ICU. Large amounts of fluids, medicines, supplies
and accessories, instruments, linen, and medical
equipment need to be stored near the patients. In a
critical care unit, there is usually a medication room,
a dirty and a clean utility room and a small
laboratory. Most intensive care units also have a
waiting room for family members.
physician working in the ICU has the unique task of
having to consider the effect of his decisions on all
body systems, while trying to preserve life. The
decision making in ICU is often done under very
critical circumstances.
The critical care area is one of the busiest and
demanding areas in the hospital. The combination
of in-depth patient care, support to the family
members, sophisticated life support systems and the
need to interact with many other health care
professionals requires the modern day intensive
care nurse to be a multi-skilled practitioner.
 One pre-requisite is an understanding of the
clinical needs of the intensive care patient. Nurses
must have the ability to continually assess the
patient and interpret monitored information and
rapidly react to changes in patient’s condition.
Critical care nurses combine their experience,
knowledge and intuition to the decision making in
the patient care process.
In some countries, respiratory therapists also
play a role in critical care. They are the experts on a
patient’s ventilation and oxygenation. They may take
care of a patient’s respiratory assessment, draw and
interpret blood gases, check and adjust the
1.3.3 Patient Admission
Prior to being admitted, patients are screened for the
need of intensive care by an ICU physician.
Admission to a critical care unit can be due to
virtually any disease which is currently
compromising, or will very soon compromise the
patient’s ability to maintain vital organ function.
OR
OR
PACU
ICU
ED
Ward
Imaging
Picture 8. Patient flow to and from the ICU.
On the arrival to the unit, the physician and
the nurse will assess the patient. Necessary lines for
monitoring (arterial line, pulmonary artery catheter,
etc.) may be inserted. Treatments are started with a
ventilator settings, give chest physiotherapy, suction
the patient, and give medications via nebulizers and
inhalers. They also participate in patient
resuscitations.
There is a wide variety of clinical support
service staff often included in patient’s care. For
example clinical dieticians, physical therapists,
radiology technicians, biomedical technicians,
occupational therapists, pharmacists, and laboratory
technicians may be involved. Additional services
may be needed from social workers, chaplains, ward
clerks or ward secretaries, nurses’ aids and
orderlies.
Roughly one third of all critical care patients
come to the ICU via the operating room after having
a major surgery performed, for example a heart or
brain operation (picture 8). Two thirds of the
patients come from the ED or a ward after becoming
critically ill or being in an accident.
Ward Home
HDU
Morgue
close observation to the effects. Mechanical
ventilation may be necessary to ensure proper
oxygenation of the tissues.
B e gi n n er ’s G ui de 17
1.3.4 Patient Care
Vital Organ Function
The most important task in the intensive care is to
support the vital organ function, to take care of
sufficient oxygen delivery to the tissues. The
patient’s ventilation, oxygenation, and blood
circulation are continually monitored for possible
changes. They may be supported with a wide variety
of fluids, medications, and medical equipment, for
example ventilator, oxygenator, dialysis machine, or
intra-aortic balloon pump.
Meanwhile, the main disease is treated with
medical or surgical interventions. There are some
conditions which have no other cure but time. Then
the disease is just let to run its course, while
patient’s vital functions are supported.
Patients are usually treated for pain with
intravenous medicines. They are also sedated as
necessary. It is common in the ICU for the patient to
become confused, delusional, or agitated. Reasons
for disorientation vary from medication side effects
to metabolic changes due to the main illness, from
lack of sleep to constant audible and visual stimuli.
Nutrition
The patients’ stay in the intensive care varies from
less than 24 hours to months. Maintaining adequate
nutrition is necessary. If the patient’s stomach and
bowel are intact, he can be fed enterally (to his
stomach or bowel) via a feeding tube. If that is not
possible the nutrients (glucose, amino acids, fat,
vitamins, and minerals) can be given parenterally
into patient’s central vein via a catheter.
It is important that administering the nutrients
is based on a skilled nutritional assessment. It has
been shown that adequate assessment and
administration of nutrients can reduce patient stay
in the intensive care and save costs both in the long
and short term.
Basic Care
If patient is on a ventilator, his care includes
1.3.5 Rehabilitation and Discharge
Being critically ill takes its toll from patient’s general
condition and muscle strength. The longer the
course of illness, the longer it takes to recover and
18 Be g i nne r ’s Gu i d e
suctioning and mouth care to remove secretions and
to prevent infections. His position needs to be
changed at times to improve ventilation of different
lung areas and to prevent skin pressure sores. Daily
care of an ICU patient also includes caring for
patient’s hygiene, skin care to prevent skin
breakdown, and range of motion exercises to keep
muscles, joints, and tendons flexible.
Family
Being admitted to an ICU is always a very stressful
situation for both to the patient and his family. The
patient’s close relatives need to be well informed
about the patient’s condition. Nurses and physicians
must support the family and look after their well-
being, as well. They need to make sure that the
patients’ relatives remember to eat and are able to
sleep. The family must have the strength to support
the patient, since their support is very important to
his recovery.
Information Management
The patient care process is well planned. Both
physicians and nurses make care plans for the
patient with assessment, goals, interventions, and
evaluation of care. Assessing a patient includes
looking, listening, and feeling the patient, checking
the data from monitors, lab work, x-rays and other
imaging. All this information needs to be available
and documented at patient’s bedside. Also, the
goals, treatments and care, and patient’s response to
them must be well documented.
The amount of information collected during
patient’s ICU stay easily becomes enormous.
Managing that data is one of the challenges of ICU
care. If the data is collected into a computer
automatically, the documentation becomes more
precise and easier to review. Automatic data
collection and information management also
provide tools for monitoring the quality of given
care.
regain one’s strength. The rehabilitation period is
hard on a patient, since his co-operation is needed at
all times. Constant support, reassurance, and
encouragement from physicians, nurses, and family
members help the patient to recover and leave the
ICU.
When patient’s condition is stable and the
underlying disease is cured, the physician will
discharge the patient from the ICU. Depending on
how much assistance, monitoring and care the
patient needs, he will go to a step-down unit or to
the ward for further rehabilitation. Most patients
survive and do well after being in a critical care
unit. The survival rate varies between 70-98 %
depending on the unit type. Surgical ICU’s have the
highest survival rates, since the care is well planned
ahead and patients are screened prior to surgery.

1.3.6 Ethical Considerations

Because of the nature of critical care, ethical issues
are addressed daily. There are complications and
side effects to all treatments used in the ICU.
Physicians are constantly weighing the effects of
starting a treatment, will it do more harm or good to
a patient.
Besides the side effects, most treatments used
in ICU cause pain to a patient. All unnecessary
suffering should be avoided. Although the patients
are medicated for pain, one of the few things they
remember from the time they spent in ICU, is the
pain.
The patient’s autonomy is to be respected. ICU
patients are often sedated and not capable of
deciding for themselves. There are cultural
differences in how much the family members are
involved in deciding for the patient. Significant
others may not always understand all of the
different aspects of care. Naturally, they are
involved emotionally, and their thinking is often
subjective. Yet all patients are individuals, and the
decisions on their care should not be done solely on
the basis of statistical data either.
Critical care is the most expensive care area in
a hospital. Yet the expense should not be a reason to
give or withhold a treatment. Everybody should
have a right for treatment. The decisions around
critical care should be done on the basis of fairness
and equality, not money.

TASKS 1.3 Critical Care

Q1 The goal of critical care is __________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Q2 What things are considered when designing a critical care unit? _________________________________
_________________________________________________________________________________________

Q3 What does a respiratory therapist do in the critical care area? ___________________________________

_________________________________________________________________________________________

Q4 The most important task in patient care is ____________________________________________________

_________________________________________________________________________________________

Q5 A critical care patient can be fed either _________________________ or ___________________________

Q6 A patient is discharged from ICU when ______________________________________________________

_________________________________________________________________________________________

B e gi n n er ’s G ui de 19
1.4 Transport
The act of moving a patient from one place to
another is called transport. All patients encounter
some form of transport during their care period.
Patients may be moved within the hospital, into the
hospital from the ‘outside world’, or from the
hospital in to another facility or the patient’s home.
No transport is without its risks. For example,
patients react physiologically in unpredictable ways,
and thus a patient’s condition may drastically
deteriorate during transport. Transport providers
must be knowledgeable and prepared to meet a
variety of challenges which may occur during
patient transport.
One of the main goals of transport is safety.
Each decision to transport a patient is based on an
assessment of the patient’s well-being, and the care
goal which would be reached by transporting the
20 Be g i nne r ’s Gu i d e
patient. The choice to transport a patient is made by
reviewing risks and benefits for the patient, as well
as the feasibility of transport and its accordance
with local policies and procedures.
If a patient is being moved from an operating
room to an intensive care unit, the transport team
must provide the same levels of care that the patient
would receive in either of these locations. In the
same way, trauma patients who are brought to the
hospital’s emergency unit must receive intensive
care during their transport. Likewise, if a patient is
being transported to a long-term care facility, the
care during transport should equal that of the care
to be received upon arrival. The care which is
provided must be timely, effective, correct, and
professional in nature.
1.4.1 Principles of Safe Transfer
Prepared and adequate numbers of staff
Appropriate equipment and mode of transportation
Extensive monitoring
Careful stabilization of the patient
Full, continual assessment, care, and review
Accurate documentation
Direct handover
(Adapted from Wallace and Ridley, Transport of critically ill patients, 1999)
Staffing for a transport depends on the type and
number of patients. Physicians, nurses, paramedics,
or emergency technicians care for the patient during
transport. It is important for the team to have a
leader, and for each member to know their own role
in the transfer. There should be enough people, yet
there should not be too many.
After a thorough assessment of the patient’s
condition and needs, the transport team’s goal of a
safe transport is initiated by stabilizing of the patient
before the transport. All equipment pertinent to
current care, as well as equipment which may be
needed, is taken. Patients who are intubated must be
mechanically ventilated, and an adequate gas supply
1.4.2 Modes of Transfer and Associated Risks
Situations which occur outside of the hospital and
require transport to the hospital usually lead to
either self-transport (own car, cab, etc.) or the use of
an ambulance. Transfers which occur as a result of
an institutional based decision are arranged by the
institution. Assessment of the patient’s needs leads
to the choice of an optimal mode of transport.
In emergency medicine, there is a standard
called the ‘golden hour’. This means that after a
medical event has occurred, for the best outcome to
occur, there is optimally one hour from the onset of
the event until treatment starts. Newer transport
must be ensured. Medicines, intravenous fluids and
medications, drainage tubes, traction, and other
medical equipment which the patient had before the
transport must all be brought along. Medical and
nursing records, x-rays, laboratory reports, transfer
papers, and other material relevant to the patient’s
care must be brought along.
Ideally, the receiving unit should have a report
of the patient they are going to receive, and an
estimated time of arrival. This gives the receiving
area time to correctly prepare for their new patient.
Both the patient and significant others people
involved in the patient’s care must be informed of
the transfer.
methods, such as air transport, have increased the
chance for survival for people in remote areas, who
would not otherwise receive care quickly.
No matter what the mode of transport is, there
are a lot of risks involved. Transport modes are
dangerous, there may be accidents, pressure
changes, temperature fluctuations, lack of power, or
shortage of equipment. Also, there is a chance for
machine failure and gases, fuel, or electricity may
become depleted. With experienced, prepared staff,
and thorough preparation, most transports are
preformed successfully.
B e gi n n er ’s G ui de 21
TASKS 1.4 Transport
Q1 What is the main goal of any patient transport? ________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q2 The principles of safe transfer are ___________________________________________________________ ,

________________________________________________, ________________________________________ ,
________________________________________________, ________________________________________ ,
________________________________________________, and _____________________________________

Q3 Name some risks involved in patient transport: ________________________________________________

__________________________________________________________________________________________

Q4 How are the risks avoided? __________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

22 Be g i nne r ’s Gu i d e
2 BASIC PHYSIOLOGY
Learning objectives: 1 have some basic knowledge about the possible
After studying this chapter you will problems in the oxygen delivery process
1 have some basic knowledge about what can be
1 know the vital functions of the body done to take care of these problems
1 understand how the oxygen is delivered to the
tissues

2.1 Breathing
Every cell in the human body needs oxygen (O2) to for the circulatory system to carry to the organs and
survive. The respiratory system provides the oxygen tissues.

CO2

O2 O2 Arterial Oxygen
Venous Oxygen
Content (~SvO2) Content (~SaO2)

O2
CO2
O2 Loading O2 O2
Hb
Hb station
O2
O2
Hb
CO O
CO2 2 2

Hb
CARDIAC
Oxygen Oxygen OUTPUT
extraction Tissue delivery
demand
O2 OCO O2
2 O2
2 O2

Hb Hb

Picture 9. The oxygen transport system.

The lungs are the oxygen loading station
(picture 9) where the oxygen gets to the red blood
cells which carry the oxygen to the tissues. The
heart works as a pump which keeps red blood cells
moving around the body to the tissues. As red blood
cells return to the loading station (the lungs) they
have given up some of their oxygen load.
An inspiration (a breath in) brings oxygen to
the lungs. From the lung’s distal part, the alveoli,
some of the oxygen is taken into the bloodstream by
diffusion. Then the oxygen is carried by the
circulating blood to the vital organs and tissues, and
released to the organs and tissues during perfusion
to keep them oxygenated.

B e gi n n er ’s G ui de 23
 Organ and tissue cells use the oxygen as fuel to
produce energy by metabolism. One product of this
metabolic process is carbon dioxide (CO2) which is
eliminated via blood circulation back to the lungs
and blown out during expiration (a breath out).
The movement of gas into and out of the lungs
is called ventilation. Both ventilation and
circulation need to be in balance to ensure adequate
oxygenation and metabolism of the organs and
tissues.
2.1.1 The Respiratory Organs
The Lungs
The lungs consist of the tracheobronchial tree and
the alveoli (picture 10). The right lung has three
lobes and the left lung two lobes, reserving a space
for the heart. The space for the lungs in the body is
called the thoracic cavity.
Two thin layers of tissue, the pleurae, cover
each lung and the inner walls of the thoracic cavity.
intrapulmonary
pressure
intrapleural
pressure
Picture 10. The lungs.
The Conductive Airways
The nose, the throat (pharynx), the windpipe
(trachea), the bronchi and the bronchioles form the
conductive airways (picture 11). The nose purifies,
warms and humidifies inhaled gases. Moisturizing
the inhaled air is vital for the mucous membranes of
the airways and the lungs.
The throat is a common passageway for air and
24 Be g i nne r ’s Gu i d e
Respiration refers to the act of breathing. It
originates from Latin: “re” means back and forth
and “spirare” means to breathe. In medical
terminology, respiration includes all exchange of
oxygen and carbon dioxide between the lungs and
the atmosphere (ventilation), the lungs and the
blood (diffusion), the blood and the cells (perfusion
and diffusion) and within the cells (metabolic gas
exchange).
The space between these two layers is called the
pleural cavity, and contains a small quantity of fluid
which prevents friction against the rib cage during
the movement of the lungs during inspiration and
expiration. Under normal conditions, the
intrapleural pressure is negative.
500
volume
250 ml
0
10
0 cmH2O
- 10
inspiration expiration
food. An open epiglottis allows air to enter the lungs.
The epiglottis is located above the larynx which
protects the airway and contains the vocal cords
that enable speech. Swallowing is caused by nerve
reflexes which close the epiglottis over the
windpipe, leading food into the esophagus
 The Alveoli
The terminal bronchioles open into alveolar sacs
which contain several alveoli, the smallest parts in
the lungs. The diameter of these tiny cavities is only
0.1 mm, but the more than 300 million of them take
up a volume of a few liters and spread out, would
cover a surface area of 70-100 m2. During
inspiration, the alveoli distend with the air flowing
into them, and during expiration the air is driven
out of the lungs and the alveoli deflate.
The alveoli are surrounded by a network of the
smallest blood vessels, the capillaries which bring
blood into contact with the alveolar walls. Oxygen
diffuses through the wall into the blood, and carbon
dioxide diffuses into the alveoli from the blood
Picture 11. The conductive airways. (picture 12). Diffusion always proceeds from a
higher concentration and pressure area to a lower
Air enters the lungs via the trachea which then one (see picture 15).
branches into two main bronchi. The right main
bronchus continues almost straight down the course
of the trachea, while the left one turns more
sideways. The bronchi further branch into smaller
and smaller bronchioles. The trachea, the bronchi,
and the bronchioles form the “tracheobronchial
tree”.
There is no gas exchange in the conductive
airways. This is why this space is commonly referred
as the anatomic dead space. In adults, the volume of
that space equals approximately the body weight in
kilograms multiplied by 2.2. Thus, for a 70 kg person,
the conductive airways take up 150 ml of the total
volume of one breath which is 500 – 700 ml. Picture 12. The alveoli and capillaries.

2.1.2 Mechanics of Breathing

The diaphragm is the main inspiratory muscle. It

separates the thoracic cavity from the abdominal
cavity. The other inspiratory muscles are the
external intercostal muscles which run forward
obliquely and downward from rib to rib.
Inspiration results from muscular contractions
of the diaphragm and external intercostal muscles
(picture 13). When the diaphragm contracts, it
moves towards the stomach. The contraction of the Diaphragm
external intercostal muscles expands the chest
outward. These movements of the diaphgram and
Inspiration Expiration
the chest increase the volume of the chest creating a
subatmospheric pressure which draws air into the
lungs (picture 8). Picture 13. Inspiration and expiration.

B e gi n n er ’s G ui de 25
 Maximum Typical adult
inspiration values
TLC 5000 ml
TLC

IRV
VC IC VC 3500 ml
TV Normal FRC 3000 ml
breathing FEV1 70-85 %
IRV 2000 ml
ERV

Maximum
FRC

ERV 1000 ml
expiration RV 1800 ml
RV RV
TV 500 ml

Picture 14. Lung capacities and volumes.

On expiration, the muscles relax and the
thoracic cavity returns to its original volume,
pushing air out of the lungs. Inspiration is an active
process and expiration happens passively.
The measurement of various lung volumes and
capacities gives information on the lungs’
ventilatory capability (picture 14). Total lung
capacity (TLC) is the total volume of air in the lungs
at maximal inspiration. Vital capacity (VC) is the
highest volume of air that can be expired after a
maximal inspiratory effort. VC is frequently
measured as a clinical estimation of pulmonary
function. Functional residual capacity (FRC) is the
volume remaining in the lungs after a normal
expiration. Inspiratory capacity (IC) is the volume
of maximal inspiration after a normal expiration.
The fraction of the vital capacity expired during the
first second (FEV1) gives information on the ease of
expiration.
Inspiratory reserve volume (IRV) is the
maximum volume of air that can be inspired in
addition to a normal inspiration. Expiratory reserve
volume (ERV) is the maximum volume of air that
can be expired after a normal expiration. Residual
volume (RV) is the volume remaining in the lungs
after a maximal expiration. RV cannot be measured
directly.
The amount of air that moves into and out of
the lungs during each breath is called tidal volume
(TV). It is approximately 7-10 ml/kg of body weight.
The volume of air moving in and out of lungs in one
minute is called minute volume (MV). It is
calculated as follows:
Minute volume (MV) =
Respiratory rate (RR) x Tidal volume (TV)

2.1.3 Regulation of Breathing

Normal breathing is automatically controlled, a
subconscious action even during critical illnesses.
Being out of breath after hard exercise or suffering
from a severe cold brings the normally subconscious
function to the consciousness.
The automatic regulator of ventilation is in the
medulla part of the brain stem. It regulates the
depth and speed of breathing according to body’s
needs. Information about pO2 and pCO2 levels from
different parts of the body is transferred to the brain
by various receptors and respiratory rate and
volume are adjusted accordingly.
Breathing can be consciously adjusted by the
cerebral cortex, the superficial layer of the
cerebrum. The conscious effort needed for taking a
deep breath or blowing a candle originates in the
cerebral cortex. The normal respiratory rate (RR)
for an adult at rest is 12-15 breaths/minute and for a
newborn baby 30-40 breaths/minute.
The main stimulus for breathing is an increase

26 Be g i nne r ’s Gu i d e
in the pCO2 level in the blood and the acidosis (a
change in acid-base balance) it produces. PCO2 level
may rise due to hypoventilation, caused by a too low
breathing rate or too small volume of breaths. If the
breathing rate is too fast or breaths are too large by
volume, this is called hyperventilation. It causes the
pCO2 level to drop, and the acid-base-balance
changes to alkalosis.
For the body cells to work efficiently, the acid-
base balance must be nearly normal. Severe acidosis
or alkalosis effects cells’ enzymatic functioning, the
actions of given medications, and may even damage
cells.
2.1.4 Problems Associated with Breathing
For a person to be able to breathe, the respiratory
regulator system must be intact and the stimulus
(mostly CO2) present. The respiratory tract must be
intact and open. The respiratory muscles need to be
functioning and there needs to be strength to
breathe. In the alveoli, the ventilation and perfusion
must come into contact.
Ventilation
Ventilation is the movement of gases into and out
from the lungs. All parts of the lungs are not
Respiration rate/min 30
Tidal volume 200 ml
Dead space 150 ml
Minute volume 30 x 200 ml = 6000 ml
Alveolar ventilation 30 x (200-150) ml = 1500 ml
Table 4. The effect of respiration rate and tidal volume on alveolar ventilation. There is a dead space of 150 ml.
Perfusion
Circulation carries the blood to all tissues and
organs. Perfusion means the blood flow through the
capillary bed. Perfusion of the pulmonary
capillaries is a prerequisite for the diffusion of
oxygen from the alveoli and of carbon dioxide to the
alveoli. It is influenced to a great extent by gravity:
in the upright position more blood is present at the
basal part of the lung than in the top area. When
lying on the back, the back areas of the lung contain
more blood. Thus the distribution of lung perfusion
varies and some capillaries are normally closed.
The medulla’s work as a respiratory generator
can be affected by various medications used for pain
control or sedation of a patient. If a patient is
mechanically ventilated with a ventilator and
medulla’s work is interrupted with sedative
medications, the patient’s pCO2 and pO2 levels are
monitored closely. Blood gas samples are analyzed
for PaCO2 and PaO2 in the laboratory. The ventilator
settings are adjusted according to the monitoring
values and blood gas sample results.
ventilated as much at all times. The distribution of
gas within the lungs depends on the posture and on
the elasticity of the lungs. The amount of lung
ventilation is affected by the dead space and by the
depth and rate of respiration.
The part of tidal volume which remains in the
conductive airways, is called the anatomical dead
space. Because of the dead space, rapid and shallow
breathing produces much less alveolar ventilation
than slow and deep breathing at the same minute
volume (Table 4).
12
500 ml
150 ml
12 x 500 ml = 6000 ml
12 x (500-150) ml = 4200 ml
Diffusion
Diffusion is the spontaneous movement of
molecules from a region of higher concentration/
partial pressure to a region of lower concentration/
partial pressure. The oxygen and carbon dioxide
molecules diffuse through the alveolar wall
separating the alveoli from the blood. O2 diffuses
from the alveoli to the blood and CO2 from the
blood to the alveoli (picture 15).
The diffusion boundary is a semi-permeable
membrane, called the alveolar capillary membrane.
Factors which effect the diffusion process, include
B e gi n n er ’s G ui de 27
 160
140 O2
120
100
mmHg

80
60
40 CO2

20
0
Air Alveoli Artery (O2)/Vein (CO2) Tissue

Picture 15. Partial pressures of oxygen and carbon dioxide.

the thickness and integrity of the membrane,

pressure differences between alveolar air and the
capillary blood, and the effective area of diffusion.

Picture 16. Normal ventilation and perfusion.
Picture 17. Shunt perfusion. Ventilation is reduced, yet
perfusion in the capillaries is normal. So the passing blood
cannot be oxygenated and CO2 can not be removed.
Picture 18. Reduced perfusion. There is no blood flow in the
capillaries. So no gas exchange can happen.
Ventilation/Perfusion Mismatch
Both ventilation and circulation in the alveoli need
to be in balance to ensure adequate oxygenation
and removal of carbon dioxide (picture 16).
Ventilation/perfusion mismatch means imbalance
of the two.
Shunt perfusion means that some parts of the
lungs are well perfused but poorly ventilated
(picture 17). Shunt perfusion decreases arterial
blood oxygen content as the poorly or non-
oxygenated blood mixes with blood from ventilated
parts of the lung.
If the alveoli are ventilated, but there is poor or
no perfusion, it is called alveolar dead space
ventilation (picture 18). Also, there may be good
ventilation, but a diffusion barrier prevents oxygen
and carbon dioxide diffusion between alveoli and
capillaries (picture 19). It results in poor
oxygenation of the blood and increased carbon
dioxide levels.

Picture 19. Diffusion barrier.

28 Be g i nne r ’s Gu i d e
2.1.5 Assisting Patient’s Breathing
If there are problems with a patient’s oxygenation,
extra oxygen may be given. That can be done using a
nasal cannula or a mask, or mechanical ventilatory
support may be necessary. During anesthesia it is
often necessary to ventilate the patient
mechanically to compensate for the depressant
effects of the anesthetics, analgesics and
neuromuscular blocking agents. Or if patient’s
ventilation and CO2 removal is not adequate because
of an illness, a ventilator is usually needed.
The application of mechanical ventilation does
not correct the underlying disorder. It only supports
the respiratory system until the appropriate
therapies, such as bronchial hygiene and
administration of antibiotics, can be applied to treat
the underlying disease.
Intubation
When a patient is intubated, an endotracheal tube
(ET-tube) is inserted into his trachea through his
mouth or nostril (picture 20). Tubes for adults have
an inflatable cuff which inhibits air leaks and helps
to prevent regurgitated stomach contents from
entering the lungs. During intubation the patient is
sufficiently medicated for sedation and relaxation.
Picture 20. Endotracheal tube in place.
To prepare the patient for intubation, pure
oxygen is normally administered to help prevent
oxygen depletion (hypoxia). This is called
preoxygenation, during which time the monitoring
of expiratory O2 (EtO2) and the difference between
the inspiratory and expiratory O2 (I-E O2) helps to
determine the adequacy of oxygen reserves and thus
the correct time for intubation.
Some of the most common complications
related to intubation include placing the tube into
the esophagus instead of into the trachea, or
advancing the tube too far, into the right bronchus.
Obstructions in the tube (e.g. mucus, blood) may
also occur. Adequate monitoring of ventilatory
parameters such as EtCO2 and the airway pressures
and volumes can prevent most of these events.
If a patient needs to be intubated and
mechanically ventilated for a while, he may have a
tracheostomy done. It means surgically creating an
opening through the neck and inserting a
tracheostomy tube into the trachea. A tracheostomy
tube causes less dead space and resistance in patient
circuit. For the patient it feels better than the ET-
tube, makes mouth care easier, and lessens a change
of sores in mouth’s mucous membranes. Patient may
be able to drink and eat with the tracheostomy tube
in place. Getting up out of bed is also easier and
safer.
Moisturizing the Gases
When breathing ambient air through the nose, there
is a loss of heat and moisture from the lower part of
the respiratory tract. The losses are quite small,
normally 7 mg/l. This is because the upper part of
the respiratory tract acts as a heat and moisture
exchanger, bringing back a large part of the expired
heat and moisture. Breathing moist and warm air
helps to keep lung membranes intact.
During intubation, the natural mechanism of
heating and moisturizing ventilated gas is less
efficient, and the inspired gases may be very dry.
Intubation requires artificial means to keep inspired
gases heated and moist. There are two ways of doing
this:
1 Heated humidifier. The inspired gas is enriched
with heat and moisture.
1 Heat and moisture exchanger. It works like the
upper respiratory tract and a good one keeps the
moisture loss at its normal value 7 mg/l. This is
sometimes referred to as the “Swedish Nose”, and
is placed between the endotracheal tube and the
breathing tubes.
B e gi n n er ’s G ui de 29
Mechanical Ventilation physiological PEEP. Intubation reduces this natural
Immediately following intubation, the patient is PEEP.
usually connected to a ventilator (picture 21 and 22). PEEP decreases intrapulmonary shunting,
The ventilator takes over the task of breathing for increases the functional residual capacity, improves
the patient, whose respiratory functions are compliance, decreases the diffusion distance for
impaired. oxygen, and improves oxygenation.
The ventilator delivers air and oxygen with
positive-pressure breaths to the lungs. This supports Ventilation Modes
gas exchange, opens or maintains ventilation of
There are many methods by which the patient and
alveoli where gas exchange occurs, and allows the
the ventilator interact to perform the ventilatory
respiratory muscles to rest until the patient is able to
cycle. These variable techniques are called modes of
breathe independently.
mechanical ventilation.
New modes are developed in an effort to
Goals of ventilator treatment are:
improve the efficiency of mechanical ventilation.
1 To remove CO2 which is produced in the cells
The various modes of ventilation give the clinician
1 To oxygenate the blood
1 To humidify the airways
1 To support spontaneous ventilation
1 To decrease the work of breathing

The ventilators on the market vary in terms of

how they control ventilation, and how they detect
changes in the patient or the equipment status.
Generally, all modern ventilators can perform the
same basic functions, but the models vary widely in
their capabilities and features.
The ventilator is set according to patient’s
needs. Normal settings for an adult, for example,
are:

1 Respiratory rate (RR) 10 - 20 breaths/min

1 Inspiratory- to Expiratory Ratio (I:E) 1:2, that is 1/
3 of the respiratory cycle is spent in inspiration
and 2/3 in the expiratory phase.
1 Tidal volume (VT) 5 – 8 ml/kg (body weight)
1 Oxygen concentration 21-100 %
1 Positive end expiratory pressure (PEEP) 5-10
cmH2 O
Positive end expiratory pressure (PEEP) is an
application of a constant, positive pressure in the
airways. This means that, at end-expiration, the
pressure inside the lungs is never allowed to return
to atmospheric pressure. PEEP is usually measured
in centimeters of H2O.
The resistance of the upper and lower airways
causes a natural PEEP of 5 cmH2O in the lungs,
preventing them from collapsing. That is called
Picture 21. In the 1950’s, there was a polio epidemic in
Denmark and Sweden. 90 % of the patients died even if the
iron lung was used. This was convincing proof of the need for
improvement in the ventilation care of patients with partial or
total breathing paralysis. The Swedish physicist Carl Gunnar
Engström (above) developed the volume-controlled ventilator,
and the hospital staff was specially trained. The ventilator
became world-famous. In the recent years, there has been a
rapid development of new technology and features in the
critical care ventilator. Now, ventilators support spontaneous
breathing and include advanced monitoring features and
information networking which make the ventilator far more
safe and comfortable for both patients and staff.

30 Be g i nne r ’s Gu i d e

Picture 22. After intubation the patient is connected to a
ventilator.
the opportunity to change the therapeutic method
when the patient’s condition changes.
When setting a ventilator several things are
considered:
Triggering = initiation of gas delivery by the
patient. If the patient is unable to trigger the
ventilator, or triggering is very hard, the work of
breathing increases enormously. If triggering is too
sensitive, there may be spontaneous cycles without
any breathing effort from patient which may lead to
hyperventilation and decreased CO2 levels. Or it
may lead to too short expiration time and increased
CO2 levels.
Gas flow limit. The flow from the ventilator
may be terminated when the pre-set volume is
reached (Volume Controlled Ventilation) or when
the pre-set pressure in the airways is reached
(Pressure Controlled Ventilation).
Cycling. The flow rate and shape, inspiration to
expiration ratio, and timing of all proportions.
Various authors and manufacturers use
different terms to describe the same functional
mode. Here are some frequently used terms related
to ventilatory treatment.
SIMV (Synchronized Intermittent Mandatory
Ventilation). The ventilator attempts to deliver
mandatory breaths in synchrony with the patient’s
spontaneous inspiratory effort. If no inspiratory
effort is detected, the ventilator delivers a
mandatory breath at the scheduled time. This
assures the set minute volume to be delivered.
PS (Pressure Support) is a mode of ventilation
during which the patient’s spontaneous respiratory
activity is augmented by a preset inspiratory positive
pressure. When the patient starts inspiration, the
pre-selected pressure support is applied and then
held constant throughout inspiration, thereby
promoting the flow of gas into the lungs. With the
set support pressure, there is no set tidal volume.
The tidal volume is variable, being determined by
the patient effort, the amount of applied pressure
support, and the compliance and resistance of the
system (patient and ventilator).
VAPS (Volume Assured Pressure Support) is a
mode of pressure support which ensures that a set
volume of gas is delivered to the patient.
CPAP (Continuous Positive Airway Pressure) is
positive pressure applied throughout the respiratory
cycle of the spontaneously breathing patient. The
advantages of CPAP are that it reduces atelectasis
and prevents fluid leakage from capillaries into the
alveoli. CPAP is commonly used to treat patients
with pulmonary edema. CPAP maintains and
promotes respiratory muscle strength because the
patient is given no other ventilatory assistance and
therefore does all the work of breathing (WOB).
CPAP can be used during weaning together with
pressure support.
APRV (Airway Pressure Release Ventilation) is
two levels of CPAP that are applied for set periods of
time. This mode allows spontaneous breathing to
occur at both pressure levels.
Weaning
When the patient no longer needs ventilator support
he is weaned from the ventilator. It is done by
reducing the support the ventilator gives to the
patient’s spontaneous breathing by decreasing the
settings.
Weaning may take a few hours to several days,
depending on the patient’s condition and how long
he has been on the ventilator. During weaning, it is
very important to monitor the patient’s oxygenation,
ventilation, and hemodynamic status to see how the
weaning is tolerated and to help recognize possible
complications.
B e gi n n er ’s G ui de 31
Extubation
Extubation means taking out the endotracheal tube.
When it has been established that the patient is able
to breath easily on his own and he has no
oxygenation problems, he is extubated or
decannulated. Decannulation means removal of the
tracheaostomy tube. After extubation the patient
needs careful monitoring for the ease of ventilation
and gas exchange. Extra oxygen may be delivered
via a facemask or nasal cannula.
Nebulization
Nebulization means giving liquid medication as a
mist via the airways. The inhalation allows rapid
local delivery of the drug to the lung tissue with
minimum toxic effect. Pneumatic driven nebulizers
are used within the ventilator circuit. Ultrasonic
nebulizers can be used with or without the
ventilator.

TASKS 2.1 Breathing

Q1 The conductive airways consist of ___________________________, _______________________________,
_________________________, ____________________________, and _______________________________

Q2 What is the role of epiglottis? ________________________________________________________________

__________________________________________________________________________________________

Q3 What does “anatomical dead space” mean? ____________________________________________________

__________________________________________________________________________________________

Q4 The inspiratory muscles are _______________________________ and ______________________________

Q5 What is the main stimulus for breathing? ______________________________________________________

Q6 What is ventilation? ________________________________________________________________________

__________________________________________________________________________________________

Q7 Perfusion means ___________________________________________________________________________

Q8 What is diffusion? __________________________________________________________________________

__________________________________________________________________________________________

Q9 Some complications of intubation are ________________________________________________________ ,

__________________________________________________________________________________________
and ______________________________________________________________________________________

Q10 The moisture loss during normal breathing is __________________________________________________

Q11 The goals of ventilator treatment are _________________________________________________________ ,

_____________________________________________, ___________________________________________ ,
_________________________________________, and ____________________________________________

32 Be g i nne r ’s Gu i d e
2.2 Heart and Blood Circulation
CO2

O2 O2 Arterial Oxygen
Venous Oxygen
Content (~SvO2) Content (~SaO2)

O2
CO2
O2 Loading O2 O2
Hb
Hb station
O2
O2
Hb
CO O
CO2 2 2

Hb
CARDIAC
Oxygen Oxygen OUTPUT
extraction Tissue delivery
demand
O2 OCO O2
2 O2
2 O2

Hb Hb

Picture 23. The oxygen and carbon dioxide transport system.

The circulatory system serves as a transport system

for the body (picture 23). The circulatory system’s
primary function is to supply O2 and nutrients to the
tissues, return CO2 to the lungs, and other waste
products of metabolism to the liver and kidneys. It
also has a role in the regulation of body temperature
and in the distribution of hormones and other
molecules which regulate cell function.
Picture 24. Different vessels.
Blood carries all necessary substances to and
from the tissues. The heart pumps the blood to all
tissues in the body through a closed system of blood
vessels. The blood vessels that leave the heart are
The Blood
called arteries (picture 24). These branch into The blood is composed of plasma and blood cells.
smaller arteries, called arterioles which end in 55 % of the blood is plasma. It consists of water,
capillaries where the actual gas exchange takes proteins, nutrients, hormones, sodium, chloride and
place. The arterioles have little muscular rings, waste products. There are three different types of
called sphincters which can constrict the blood’s cells which make up 45 % of the blood. The cells are
flow into the capillaries. The other end of a capillary red blood cells for transporting O2, white blood cells
opens into a venule. Venules connect into veins for defense against infection, and platelets whose
which return the blood to the heart. main function is in blood coagulation.

B e gi n n er ’s G ui de 33
 Red blood cells contain a special substance
called hemoglobin. It captures the oxygen molecules
diffusing from the alveoli into the pulmonary
capillaries, and becomes oxygenated (HbO2 =
oxyhemoglobin). When blood reaches the tissue or
organ that needs the oxygen, oxygenated
hemoglobin releases the oxygen and becomes
deoxygenated (Hb). The ability of hemoglobin to
capture and release O2 is affected by pH (acid-base
balance of blood) and temperature, amongst other
factors.
Hemoglobins which are capable of carrying
oxygen (Hb, HbO2) may be called functional
hemoglobins. There are also small amounts of
dysfunctional hemoglobins in blood. They are not
capable of carrying oxygen. They are for example
carboxyhemoglobin (COHb) and methemoglobin
(MetHb).
Components of Circulation
The circulatory system consists of two complete
circuits which are arranged in a series (picture 25).
The systemic circulation transports the oxygenated
Pulmonary
circulation
Systemic
Coronary circulation
circulation
Picture 25. Components of blood circulation.
34 Be g i nne r ’s Gu i d e
blood pumped from the left side of the heart to the
rest of the organs and tissues and back to the heart.
The pulmonary circulation receives deoxygenated
venous blood pumped from the right side of the
heart, transports it to the lungs to be oxygenated,
and returns it to the left side of the heart. The third
component of the circulatory system is coronary
circulation which delivers blood to the heart muscle.
Circulatory System Pressures
Pressures in different circulatory systems vary a lot.
The heart pumps blood through all the circulatory
systems to maintain an adequate blood flow. The
left ventricle has to create a lot of pressure to
overcome the high resistance of the long systemic
circulation (picture 25). The right ventricle only
needs to pump blood through the pulmonary
circulation which has a low resistance to blood flow
and thus the pressure needed is much smaller.
Blood pressure on the arterial side of
circulation is higher than on the venous side. Also,
the absolute pressure of systemic arteries is several
times greater than that of the pulmonary arteries.
The Control of Blood Circulation
Circulation is controlled by various regulatory
systems which function to maintain adequate
capillary blood flow in all organs, especially in the
heart and brain. The main regulator of blood
circulation is the cardiovascular center located in
the medulla of the brain stem. The cardiovascular
center receives input from the brain and from the
sensory receptors throughout the body. Output from
the cardiovascular center is sent via sympathetic
and parasympathetic nerve fibers of the autonomic
nervous system.
Tissue Perfusion
All the tissues of each organ need oxygen and
nutrients to survive. Good organ and tissue
perfusion (blood flow through the capillaries) is a
prerequisite for the delivery of oxygen from the
blood and the uptake of carbon dioxide by the
blood.
Tissue perfusion of different organs may be
compromised in some illnesses. Balancing body’s
circulating fluid amount and administering certain improve tissue perfusion. Nitric oxide (NO) can be
medications may improve the tissue perfusion. given with the inhaled air to dilate pulmonary
Medications like nitroglycerin can be given capillaries and improve the perfusion of the lungs.
intravenously to dilate the capillary bed and

2.2.1 Anatomy of the Heart

The aorta divides into the ascending aorta, the
Superior aortic arch, and the descending aorta. The major
vena cava Aorta arteries providing oxygenated blood to upper part of
Pulmonary
artery the body, including brain, originate from the aortic
arch. The descending branch provides blood to all
Pulmonary organs below heart level.
valve The heart is composed almost entirely of a
LA Aortic specialized muscle called the myocardium. The
Inferior
valve entire heart is covered by the pericardium, a
vena cava RA
fibrous, non-elastic sac which protects the heart.
LV
Mitral
RV
valve
Tricuspid Coronary Circulation
valve
The heart muscle has its own blood circulation
called coronary circulation. It consists of three main
Picture 26. The anatomy of the heart. coronary arteries, each of which supply different
parts of cardiac muscle with oxygen and nutrients
(picture 27). Cardiac veins return deoxygenated
The heart functions as a two-sided pump (left and
blood from the heart muscle to the right atrium.
right). It has four chambers, two atria and two
If there is a prevention of blood flow to the
ventricles (picture 26). The atria lie above the
heart muscle due to a stenosis (a narrowing of the
ventricles and are thin-walled reservoirs which
diameter of the vessel) or a spasm of a coronary
supply their respective ventricles with blood. The
artery, myocardial ischemia occurs. This means that
ventricles are thick-walled, muscular chambers. The
the heart muscle is not receiving oxygen. If the
right chamber pumps the blood to pulmonary
ischemic condition is severe or prolonged, the area
arteries, and the left chamber pumps the blood to
the systemic arteries via the aorta.
Right atrium (RA): the blood returning to the
heart from systemic circulation enters the right
atrium through two large veins, the superior vena
cava and the inferior vena cava.
Right ventricle (RV): the blood from the right
Left common
atrium enters the right ventricle through the coronary artery
Right
tricuspid valve. The blood is then pumped through coronary
the pulmonary valve to the pulmonary artery and artery Circumflex
then to the lungs. artery
Left atrium (LA): acts as a reservoir for
oxygenated blood returning from the lungs through Left arterior
the pulmonary veins. descending
Left ventricle (LV): the blood from the left artery
atrium enters the left ventricle through the mitral
valve and is then pumped into the aorta through the
aortic valve and then to the systemic circulation. Picture 27. Coronary arteries.

B e gi n n er ’s G ui de 35
of ischemic tissue becomes injured (infarct), cell
function ceases, and irreversible cell death follows.
The injured part of the heart muscle is unable to
contract. Depending on which coronary artery is
obstructed the different parts of the heart suffer
from the decreased blood flow and ischemia.
The condition of myocardium and function of
the heart valves affect the pump function of the
heart.

2.2.2 Electrical Activity of the Heart

The heart muscle, like any other muscle, needs an

electrical impulse in order to contract. There are
specialized conducting cells for impulse formation
SA node
and delivery in the heart muscle. The electrical LA
activity of the heart coordinates the mechanical RA
AV node
function of the cardiac cycle.
The cardiac cycle begins with the creation of Bundle of
an electrical impulse in the sinoatrial (SA) node His RV Purkinje fibers
LV
(sinus node, normal pacemaker), located in the right
Right Bundle Left Bundle
atrium (picture 28). The impulse forming rate is Branch Branch
adjusted according to the circulatory needs of the
body.
Picture 28. The conduction system of the heart.
The impulse advances through atria to the
atrioventricular (AV) node, through the bundle of
His and into the ventricles via the bundle branches depolarization. It stimulates the cells near by and
and Purkinje fibers. The other cells of the the depolarization is spread through the
conducting system besides the SA node also have myocardium which leads to contraction of the heart
some ability to form electrical impulses if necessary. muscle.
After depolarization, the repolarization
process begins restoring the cell membrane to its
Cellular Electrophysiology resting state again. During repolarization, the cell
The resting myocardial cells are polarized (picture cannot be reactivated.
29). The outside of the cell membrane is positively
charged while the inside is negatively charged. This
negative state is maintained by active pumping of
Normal Electrocardiogram
positive ions out of the cell. The change of the charge distribution of the heart’s
Electrical stimulus changes the intracellular muscle cells results in a measurable electrical signal,
charge from negative to positive. This is called electrocardiogram (ECG). The normal ECG signal

Resting cell Electric impulse Return to rest

= polarized = depolarization = repolarization

Picture 29. Cellular electrophysiology.

36 Be g i nne r ’s Gu i d e
consists of a series of positive and negative
deflections called P, Q, R, S, and T waves (picture
30).
Normal electrical functioning of the heart
produces a sinus rhythm (picture 30). Electrical
function of the heart is vulnerable to many factors,
for example, a lack of oxygen or an electrolyte
imbalance. The heart may also be damaged by
infarction of the muscle. These situations may
produce different arrhythmias.
An arrhythmia is an abnormal cardiac rhythm.
It may be too rapid (tachycardia) or too slow
(bradycardia). The rhythm may originate
somewhere else besides the sinus node, or the
conduction pathway may be interrupted.
Arrhythmia may affect the mechanical contraction
of the heart muscle and cause different symptoms,
like palpitations, fainting, or chest pain. Some
arrhythmias are very dangerous causing sudden
death.

— +
1) The P-wave is recorded in an ECG when the
impulse activates the atria. The normal duration
P of the P wave is less than 0.12 seconds and the
amplitude is not more than 0.3 mV.

— +
2) The activation of bundle of His is a very small
event and does not show on ECG. There is only a
P baseline seen in ECG at this point. It is called PR
interval. The normal PR interval is between 0.12
and 0.21 seconds.

— +
3) When the interventricular septum is activated
from the left to the right, the Q-wave (first stroke
P down) is recorded on the ECG.

— +
4) A tall positive stroke (R-wave) and the following
R
negative stroke (S-wave) are recorded in the ECG
P when the two ventricles are activated. The QRS
complex created by the impulse moving through
Q the both ventricles is normally 0.05 to 0.10
seconds in duration.

— +
5) Electrical currents generated during
R
repolarization of the ventricles are reflected in
T the flat portion following the QRS complex (ST
P
segment) and T-wave following it. The point
Q S where QRS ends and the ST segment begins is
called the J point.

Picture 30. Formation of ECG waveform.

B e gi n n er ’s G ui de 37
2.2.3 Functioning of the Heart

Every contraction of the ventricles delivers a certain
volume of blood into circulation. Between
contractions the heart muscle rests, becomes
oxygenated through coronary circulation and fills
up with more blood.
The period from the end of one heart
contraction to the end of the next is called the
cardiac cycle. It consists of two phases: diastole, a
period of myocardial relaxation when the heart fills
with blood, and systole, a period of myocardial
contraction when blood is pumped out of the
ventricles.

Picture 31. Pressures of the heart.

All chambers of the heart have different

pressures due to their function (picture 31). These
pressures also vary a lot during the cardiac cycle.
The amount of blood pumped out in each Rate/min

contraction is called the stroke volume (SV). The

amount pumped during one minute is called the
cardiac output (C.O.). It is determined by the heart
rate (HR) and the stroke volume (C.O. = HR x SV)
Picture 32. Determinants of cardiac output are heart rate
(picture 32). Both sides of the heart pump and rhythm (the higher the heart rate the greater the cardiac
approximately the same amount of blood to the output) and stroke volume (the greater the stroke volume the
arteries. Typical stroke volume is 70-100 ml for an greater the cardiac output).
adult. The heart beats at a rate of 60-80 beats /
minute. Therefore, normal adult cardiac output at
rest is about 5 l/minute. This varies from individual
to individual depending on body size; the larger the
person, the higher the cardiac output.
There are three factors which influence the
stroke volume and the function of the heart:
preload, myocardial contractility and afterload
(picture 33). Preload is the amount of blood which is
present in the ventricles prior to systole, that is the A B
degree to which the myocardium is stretched before
it contracts (filling pressure). Myocardial muscle
fibers need to be stretched in order to contract. The Picture 33. Preload (A) causes muscle fibers to stretch.
greater the volume of blood present in heart’s Afterload (B) is the resistance against which the ventricles
chambers before the actual contraction, the greater must pump the blood.

38 Be g i nne r ’s Gu i d e
the stretch of the myocardial fibers and thereafter
also the contraction. If the heart muscle is stretched
too much, it may lose its capability to contract, and
heart failure may occur.
Muscle fibers of the heart must be intact to be
able to contract. All fibers need energy, oxygen and
a good balance of electrolytes to perform well. Lack
2.2.4 The Components of Oxygen Delivery
The oxygen delivery system to the body tissues
consists of the lungs (correct ventilation and enough
oxygen) and the cardiovascular system (the heart
function and blood circulation). In order for oxygen
to be successfully delivered to the tissues, an
adequate amount of deoxygenated hemoglobin must
be available to bind and carry oxygen. The
Question
Does enough gas reach the lungs?
Is it evenly distributed?
Does enough oxygen reach the alveoli?
Does enough oxygen diffuse into the blood?
Can the blood receive enough oxygen?
Does the blood go where it should?
Can the blood release the oxygen to the tissues?
Can the tissue cells use the oxygen to produce energy?
Table 5. Questions related to different parts of oxygen delivery.
Nitric Oxide
Nitric oxide (NO) is a colorless and odorless gas,
a common component of traffic pollution and
cigarette smoke. NO is also a compound produced in
the vessel walls. One of NO’s functions is to dilate
the arteries and veins. For a long time, patients with
hypertension have been treated with intravenous
of oxygen leads rapidly to poor contraction of the
heart muscle.
Afterload is the resistance of the systemic
circulation against which the blood is pumped. The
higher the resistance, the smaller will be the amount
of blood pumped out of the heart (the stroke
volume).
cardiovascular system must be functioning to ensure
the blood flow to the tissues. The cellular uptake
and utilization of oxygen may not be blocked.
The following table (table 5) lists some of the
questions relevant to tissue oxygenation, as well as
their respective phases in the process of oxygen
delivery.
Phase
ventilation
ventilation
ventilation
diffusion
lung perfusion/oxygen uptake
circulation/perfusion
oxygenation/Hb dissociation (hemoglobin’s ability to combine,
carry and release oxygen molecules)
metabolism
medications like nitroglycerin and nitroprusside.
NO is the vasodilator in these drugs.
Administering drugs intravenously generally
causes a systemic effect. If only the patient’s
pulmonary blood pressure needs to be lowered, the
intravenous medications will lower the systemic
B e gi n n er ’s G ui de 39
blood pressure as well. The dilation of arteries will
also happen in all parts of the lungs, even if they are
not ventilated (picture 34). This may lead to hypoxia.
In recent years, physicians have learned to
administer nitric oxide with respiratory gases,
inhaled nitric oxide, (iNO) to treat patients,
especially newborn babies, with severe lung
problems and hypoxia. Some clinicians may utilize
iNO in many other patient applications such as
cardiac transplantation, pulmonary hypertension
(primary and secondary) and ARDS. These
applications are still considered investigational in
many areas of the world.
When nitric oxide is inhaled it diffuses quickly
from the well-ventilated alveoli directly into
pulmonary capillaries. Only the capillaries exposed
to iNO will be dilated. These dilated capillaries now
have the ability to pick up more oxygen, which leads
to improved oxygenation of the patient (Picture 34).
Nitric oxide is rapidly metabolized when it is in
contact with blood’s hemoglobin. So, it does not
have time to cause systemic vasodilatation and drop
the systemic blood pressure. The vasodilation will
only happen in the pulmonary circulation.
Airway
O2
O2
O2
O2
NTG
O2
O2 O2 O2
NTG
IV medication
Picture 34. The effect of iv medication and nitric oxide on pulmonary circulation and patient oxygenation.
NTG = nitroglycerin, NO = nitric oxide
40 Be g i nne r ’s Gu i d e
Limitations of iNO therapy
Nitric oxide is a very active gas that combines easily
with oxygen to form nitrogen dioxide (NO2). NO2 is a
toxic gas, which in high concentrations may damage
the lungs, and cause heart failure. It is very important
to monitor the NO2 level in patient’s inspiratory gas.
To prevent the conversion of NO to NO2, patient
delivered oxygen concentration is kept as low as
possible (FiO2 max 0.60). Gases coming from the
patient may be removed via a scavenging system to
help decrease the personnel exposure to the NO and
NO2. However, several clinical studies have shown
that clinician exposure to these gases are “minimal,
infrequent and well below government safety
guidelines” therefore, scavenging is really not
required. It is also strongly recommended that
delivered oxygen concentration be monitored as the
addition of NO/N2 for iNO therapy may dilute the
oxygen actually delivered to the patient.
Nitric oxide combines with hemoglobin to form
methemoglobin (MetHb). During iNO therapy,
MetHb levels are monitored frequently. If MetHb
levels should rise, the administered amount of iNO is
reduced.
Alveolus
O2
NO
NO
O2
O2 O2 O2
Inhaled NO
TASKS 2.2 Heart and Blood Circulation
Q1 What are the main functions of the circulatory system? ________________________________________
_________________________________________________________________________________________

Q2 Name the three circulatory systems. What are their functions?

______________________: __________________________________________________________________
______________________: __________________________________________________________________
______________________: __________________________________________________________________

Q3 Add the names of the various parts of the heart to the diagram below

Q4 What does ECG stand for, and what does it record? ____________________________________________
_________________________________________________________________________________________

Q5 The heart muscle is called __________________________________________________________________

_________________________________________________________________________________________

Q6 What does myocardial ischemia mean? ______________________________________________________

_________________________________________________________________________________________

Q7 Arrhythmias may be caused by _____________________________________________________________ ,

_____________________________, or _________________________________________________________

Q8 What is cardiac output and what does it indicate? _____________________________________________

_________________________________________________________________________________________

Q9 If the stroke volume of an adult at rest is 70 ml, and his heart rate is 70 b/min,
what is his cardiac output? _________________________________________________________________
_________________________________________________________________________________________

Q10 The three factors that affect the stroke volume, and cardiac output, are
________________________, _______________________, and ____________________________________

Q11 What are the benefits of delivering NO via mechanical ventilation? ______________________________
_________________________________________________________________________________________

B e gi n n er ’s G ui de 41
2.3 Metabolism
The human body is an energy machine converting
food to energy, needed for mechanical work, and
heat. The process of producing energy is called
metabolism. The cells need oxygen for fuel of this
metabolic process. Carbon dioxide is released as
side product. The energy producing process is called
oxidation (picture 35). Excess CO2 is quickly
removed by ventilation.

Nutrients Energy
+ Oxidation +
O2 CO2

Picture 35. The metabolic process.

For the oxidation process to be efficient, both
O2 and nutrients need to be inside the cell. Lack of
oxygen in an otherwise functioning cell leads to
anaerobic energy production which is less efficient
and causes lactic acid production and eventually
lactic acidosis. Acidosis interferes with cells’
enzymatic systems and may cause cell malfunction.
Severe acidosis may cause pain, and even
circulatory collapse, heart failure, and death.
The amount of oxygen consumed by the
patient (oxygen consumption = VO2) and the amount
of carbon dioxide produced by the patient (carbon
dioxide production = VCO2) are directly
proportional to the amount of energy produced at
cell level. Pulmonary gas exchange is equal to
cellular gas exchange. Carbon dioxide production
equals the amount of CO2 expired minus amount of
CO2 inspired (which usually is zero):
VCO2 = MVexp x FeCO2 - MVinsp x FiCO2
mellitus) will prevent normal energy production.
Glucose is a sugar which is produced from
carbohydrates (e.g. in rice or cereals or cane sugar)
and also through biochemical reactions in the body.
Energy Requirements
Energy is commonly measured in kilocalories (kcal)
or kiloJoules (kJ) (1 kcal = 4.19 kJ). An estimate of an
average daily energy expenditure for an adult male
is 2550 kcal (10600 kJ) and for an adult female 1950
kcal (8100 kJ). Diseases and different clinical
conditions may have a significant effect on how
many calories the patient uses (i.e. on his energy
expenditure = EE), as well as on his energy
requirements (picture 36).
%
60
50

In the same way the oxygen consumption 40

equals the amount of O2 inspired minus O2 expired: 30

20
VO2 = MVinsp x FiO2 - MVexp x FeO2
10

0
Normal basal oxygen consumption is about 250
Injury, Anxiety Fever Work of
ml/min, and carbon dioxide production is about 200 Infection breathing
ml/min.
Even if O2 is sufficiently supplied, lack of Picture 36. Examples of increase (%) in oxygen consumption
glucose in the cell (e.g. non-treated diabetes over predicted basal consumption.

42 Be g i nne r ’s Gu i d e
 Cell metabolism
Nutrients
and O2
Nucleus
Carbohydrates
Glucose
Fats Fatty acids
Proteins Amino acids
O2
Picture 37. Cell metabolism.
Temporary increases in usage of energy up to
200% can occur due to shivering or convulsions.
Hypermetabolism, such as during injury or
infection, may increase the energy expenditure in
extreme cases up to 100%. In hypothermia (body
temperature below normal) and circulatory shock
energy expenditure may decline, as well during
anesthesia or if patient is given muscle relaxants.
Balanced, adequate nutrition is essential for
the production and maintenance of the mass of
body tissue, for the support of vital activities, and for
health and recovery from illness and injury. The
digested food is pre-processed through certain steps
first to carbohydrates, fats and proteins, and further
into simpler molecules like glucose, fatty acids, and
amino acids.
Carbohydrates
The principal source of energy in most diets is
carbohydrate. If a diet is low in carbohydrates, a
greater percentage of dietary protein is used to
provide glucose which means less is available for
the growth and repair of body tissues. There are two
main types of carbohydrate in the diet: starch (e.g.
rice) and sugars (e.g. glucose). Their main function
is to provide energy which is relatively easy to
utilize by the cells.
Fat
The main functions of fat as a nutrient are to
provide a concentrated source of energy, act as a
carrier for fat-soluble vitamins and to provide
Products
Energy
CO2
Building
material
Waste products
essential fatty acids. They are important in the
formation of cell membranes particularly in nerve
tissue. Main sources of fat in a normal diet are meat
products, dairy products and oils.
Protein
The main sources of protein include meat, fish, and
dairy products. Protein is continuously being broken
down in the body, and must be continuously
replaced. The building blocks of protein are amino
acids and when they break down, nitrogen is
released and excreted into the urine. It is possible to
determine whether a person is gaining or losing
protein by comparing the dietary nitrogen intake
with the nitrogen excreted in the urine.
Within the cell, the metabolic process is
controlled by the cell nucleus (picture 37). Glucose,
fatty acids, and amino acids are used to produce
energy and building material for the cell. During
this process, carbon dioxide and other waste
products are produced, as well.
When processing different nutrients, the
amount of oxygen consumed and carbon dioxide
produced varies. The ratio between carbon dioxide
production and oxygen consumption is called
respiratory quotient (=RQ). It reveals the main
nutrient being metabolized and whether the person
is being fed adequately or gaining weight. The
amount of released energy by different nutrients
varies. For example, 1 g of fat releases more than
twice as much energy as 1 g of protein or
carbohydrate.
B e gi n n er ’s G ui de 43
TASKS 2.3 Metabolism
Q1 What is the oxidation process? _______________________________________________________________
__________________________________________________________________________________________

Q2 What is the by-product of oxidation, and how is it removed from the body? ________________________
__________________________________________________________________________________________

Q3 What happens if a cell does not get oxygen for its metabolism? ___________________________________
__________________________________________________________________________________________

Q4 Normal basal O2 consumption is ____________________ and CO2 production is _____________________

Q5 What conditions may increase metabolic rate? _________________________________________________

__________________________________________________________________________________________

Q6 What conditions may decrease metabolic rate? _________________________________________________

__________________________________________________________________________________________

Q7 Which nutrients are main sources of energy? _______________________ and _______________________

Q8 What is respiratory quotient? ________________________________________________________________

__________________________________________________________________________________________

2.4 Nervous System

Picture 38. The purpose of the nervous system.

The nervous system acts as the control and 1) to sense changes both within the body, e.g. too
communication system of the body. The nervous much carbon dioxide in blood, and outside the
system has three basic functions (picture 38): body, e.g. the smell of food

44 Be g i nne r ’s Gu i d e
2) to analyze the sensed information, store some of
it in memory, and make decisions on what to do
about the sensed changes
3) to initiate muscle movement or glandular
secretions in response to the sensed stimuli
The nervous system (picture 39) can be
devided anatomically to the central nervous system
(CNS) and the peripheral nervous system (PNS).
The CNS, consisting of the brain and spinal cord, is
the central processor of information while the PNS
acts as a route for incoming and outgoing signals.

NERVOUS SYSTEM

CENTRAL NERVOUS PERIPHERAL NERVOUS

SYSTEM (CNS) SYSTEM (PNS)

Sensory (afferent) neurons

(somatic and autonomic)
Brain

Spinal
cord Motor (efferent)
neurons

Somatic Autonomic

Sympathetic Para-
sympathetic

Picture 39. The nervous system.

B e gi n n er ’s G ui de 45
2.4.1 Brain Anatomy
The brain is located inside the skull which is not a
flexible structure in adults. The blood flow in the
brain depends on the delicate balance of the
cerebrum
thalamus
DIENCEPHALON
hypothalamus
cerebellum
spinal
cord
Picture 40. Anatomy of the brain.
Different parts of the brain (picture 40) are
responsible for different functions. The brain stem
regulates vital and other bodily functions (e.g.
heartbeat, breathing, swallowing etc.) and relays
motor and sensory impulses between other parts of
the brain and the spinal cord. The cerebellum is
responsible for balance, whereas the diencephalon
assists in sensation and movements, and controls
the autonomic nervous system. It is also the home of
feelings.
sensing
seeing
Picture 41. Functional areas of the cerebrum.
46 Be g i nne r ’s Gu i d e
systemic blood pressure, the pressure inside the
brain (intracranial pressure), and the diameter of the
vessels in the brain.
cortex
midbrain
pons
BRAIN STEM
medulla
oblongata
The most interesting part of the brain is
probably the cerebrum (picture 41) or the “big
brain” and especially its surface layer - the cortex,
where all conscious thinking takes place. It consists
of a network of neurons which communicate to
each other by sending impulses. When enough
activity is summed up, it can be measured from the
scalp as a small electric voltage – much like the
electrical activity of the heart, only ten times
smaller.
moving
talking
hearing

Circle of
Willis
Medulla
IC
V V
S S
2.4.2 Peripheral Nervous System
Peripheral nervous system consists of sensory
(afferent) neurons which bring information to the
CNS, and motor (efferent) neurons which conduct
nerve impulses from CNS to muscles and glands
(see picture 39). The PNS can be divided into
somatic and autonomic parts. The somatic part is
active when you stretch your arm, while the
autonomic part controls involuntary reactions.
These involuntary reactions can be either
sympathetic or parasympathetic. Normally the
sympathetic and parasympathetic divisions of the
autonomic nervous system (ANS) are in balance –
the activation of sympathetic system speeding
things up, and the activation of parasympathetic
system slowing things down.
Blood flows to the brain via internal carotid
arteries and vertebral arteries (picture 42). The
blood circulation of the brain has a special structure
called the Circle of Willis. This is a connecting
network of arteries which assures the perfusion of
the brain even if the blood flow is interrupted in one
artery. Changes in blood’s oxygen and carbon
dioxide levels affect the blood circulation. Also
temporary stimulation like seizure activity may
increase blood flow to affected area even four times
more than normal.
Picture 42. Blood circulation of the brain. Blood flows from
aorta (A), through subclavian arteries (S), internal carotid
arteries (IC), and vertebral arteries (V) into the brain.
The sense of danger activates the sympathetic
system, causing the heart to beat faster and the
whole body to prepare itself for fighting or running
away, slowing down digestion of food and supplying
the muscles with more blood. Examples of
parasympathetic activation include salivation,
promotion of digestion and sharpening of near
vision for reading, all of which the body has time for
when not feeling threatened. The delicate balance
between the two parts of the autonomic nervous
system is often thrown off by anesthetic drugs or
intraoperative events.
B e gi n n er ’s G ui de 47
2.4.3 Neurons and Signal Transmission
Nerve cells are called neurons and they conduct
nerve impulses between parts of the nervous
system. Some neurons are tiny, and transmit signals
over a very short distance, while others are the
longest cells in the body. For example, the toe-
wiggling motor neurons extend from just above
waist level to the toe. Most neurons have three parts:
1 The dendrites which are the receiving end of a
neuron
1 The cell body which contains functions for cell
metabolism
1 The axon which is the transmitting end of a
neuron
When the nerve cell membrane is at rest, it
2.4.4 Factors Affecting Nervous Function
Neurons are very dependent on oxygen. If blood
flow to the cells stops, irreversible damage can take
place in a matter of a few minutes. The nerves must
be intact to transmit an impulse. If there is a
blockage, for example due to an injury either in
receiving or transmitting part, a malfunction will
occur. This may present as a sensory deficit or
paralysis of a certain body part.
Many things can affect brain function. Brain
2.4.5 Regulation of Body Temperature
The physiological regulation of body temperature
takes place in the hypothalamus of the brain. It acts
like a thermostat by measuring the temperature of
the blood, receiving information from the skin
receptors, and starting balancing mechanisms when
necessary. Altered function or impairment of the
regulation mechanism, or inadequacy of the
balancing mechanisms, lead to either hyperthermia
(too high temperature) or hypothermia (too low
temperature).
48 Be g i nne r ’s Gu i d e
exhibits an electrical voltage difference across the
membrane (like a battery). When properly
stimulated, the membrane will produce responses
which will be transmitted to other neurons. These
responses are called action potentials. The impulse
moves from one neuron to another and can travel
quite long distances without dying out. Signal
transmission, once started, will continue to its
finish. That property of nerve cells can be described
by a Domino Effect (all or nothing).
All muscles need an electrical impulse in order
to contract. Some neurons are connected to muscles
and will provide that necessary impulse. At the
connection site there is a chemical transmitter,
acetylcholine which transmits the impulse from the
nerve ending to the muscle cell.
activity can change according to the state of arousal
or body temperature. Many drugs, anesthetics for
instance, either stimulate the central nervous
system or slow its activity. Chemical imbalances of
the body, for example due to a liver or kidney
disease, may slow down brain activity. In an
ischemic situation, from inadequate oxygen delivery
or decreased cerebral blood flow, the brain activity
also slows down.
Hyperthermia, to some degree, may help to
fight infections, but high temperature increases
metabolism, so the use of oxygen and the
production of carbon dioxide increase.
Hypothermia becomes harmful, since the body tries
to produce heat by shivering which again uses
oxygen and produces carbon dioxide increasing the
ventilatory needs. Hypothermia also effects the
circulatory system, as well as blood clotting
mechanisms.
Body Temperature Regulation during Anesthesia
The direct effects of anesthetics and muscle
relaxants impair the physiological temperature
regulation mechanism. During general anesthesia,
the hypothalamus is also anesthetized.
Redistribution of heat from the core to the
extremities is often present. Consequently, many of
the patients who have a normal temperature on
arrival to the OR suffer from hypothermia after the
operation.
Hypothermia during Anesthesia
Inadvertent hypothermia is often seen in long
operations and in newborn babies. The mechanisms
leading to it are radiation and convection from the
naked surface, conduction to a colder object, and
evaporation of water. Cold intravenous solutions
also cool down the patient whose regulation
feedback system has been anesthetized. During
cardiac surgery, the patient’s temperature may be
purposefully lowered to decrease oxygen
consumption and to help protect the heart while it is
not getting any blood flow.
Hyperthermia during Anesthesia
Hypertermia might be anticipated if a patient is
already feverish, has an infection or is in a hot and
humid environment. Malignant hyperthermia is an
uncommon, but potentially fatal disease which may
occur during anesthesia. It is a hypermetabolic crisis
that can be triggered by anaesthetic drugs (inhaled
anesthetics and succinylcholine). If not recognized
and treated promptly, malignant hyperthermia has a
high mortality rate. Early findings include
increasing EtCO2, followed by a rapid temperature
increase of as much as 1° C/5 minutes, unstable
blood pressure, tachycardia (HR>100 beats/min.),
and arrhythmias.

TASKS 2.4 Nervous System

Q1 The three basic functions of the nervous system are ____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q2 The central nervous system (CNS) consists of __________________________________________________

and ______________________________________________________________________________________

Q3 The autonomic part of peripheral nervous system has two different divisions. What are their names
and functions? _____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q4 The nerve cells are called ___________________________________________________________________

Q5 What may cause the brain activity to slow down? _______________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

Q6 What does hyperthermia mean? _____________________________________________________________

Q7 Why is hypothermia harmful? _______________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

Q8 How does anesthesia effect body temperature regulation? _______________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

B e gi n n er ’s G ui de 49
3 PATIENT MONITORING

3.7.3 BIS 3.6 EEG

3.1.2 Carbon dioxide 3.1.1 Spirometry

3.2.1 Patient oxygen 3.7.1 Inhalational

anesthetic agents

3.4.2 Cardiac output

3.2.3 Mixed venous

oxygen saturation
3.5 ECG

3.4.1 Blood pressures

3.4.3 Gastric tonometry

3.8 Temperature

3.2.2 Pulse oximetry

3.7.2 NMT

3.3 Gas exchange

50 Be g i nne r ’s Gu i d e
Learning objectives :
After studying this chapter you will understand
1 how patient’s vital body functions are monitored
with Datex-Ohmeda’s monitoring solutions
1 how the information is gathered and what it is
used for
When the patient is unable to take care of
himself/herself, the clinician’s main responsibility is
to ensure the well-being of the patient. Traditionally,
the clinician had to rely on the senses as well as
some basic measurements (e.g. two fingers on the
pulse) to observe the patient’s clinical status and to
decide on corrective actions. While these basic
techniques still remain the key elements in
monitoring (= watching over) patients, modern
technology can add to patient safety by offering
objective, accurate, and reliable patient data on vital
signs, in both numeric and graphic form.
3.1 Monitoring Ventilation
3.1.1 Spirometry
Patient Spirometry is a visual tool used to ensure
safe ventilation both in anesthesia and critical care.
It helps to prevent and to diagnose problems with
the ventilator or endotracheal/tracheostomy tube
through a display of various loops and curves. In
critical cases, mechanical ventilation needs to be
adjusted often in order to optimize oxygen delivery
and carbon dioxide removal.
The information from the ventilated patient is
generated from pressures, volumes, and flows
measured at the patient’s airway by Datex-Ohmeda
D-lite TM, combined gas sampler and pressure/flow
sensor. It is integrated with other parameters on the
monitoring screen in the form of quantitative and
graphical information.
Quantitative Information
1 Tidal Volume (TV) and Minute Volume (MV) are
the amount of gas delivered by the ventilator and
exhaled by the patient in one breath and in one
minute. There are inspired and expired values for
both tidal volume (TVinsp, TVexp) and minute
volume (MVinsp, MVexp).
Many countries have published either
recommendations or minimum standards of
monitoring to improve patient safety. Monitoring of
relevant parameters can help the clinician to
determine the functioning of the patient’s body from
ventilation through circulation to oxygenation and
metabolism.
In the human body, all functions work together.
Ventilation alone does not guarantee cell
oxygenation, neither does good blood pressure or
great cardiac output. The increase in the blood
pressure may be due to fluid overload, respiratory
distress, anxiety, or a variety of other causes. But
different monitoring parameters give different views
to a patient’s problem. Different monitoring
parameters are important pieces of the whole puzzle
of patient’s vital body functions. Having all the
pieces of the puzzle in hand helps the clinician to
see the whole picture and take care of the patient’s
needs.
1 I:E is the ratio between inspiratory and expiratory
times.
1 Peak Pressure (Ppeak) is the maximum pressure
exerted at the patient airway.
1 Plateau Pressure (Pplat) is the pressure in lungs
at the end of inspiration during the period of no
gas flow.
1 Mean Airway Pressure (Pmean) is the average
pressure measured across the entire breathing
cycle.
1 Positive End Expiratory Pressure (PEEP) is the
pressure remaining in the lung at the end of
expiration. The total PEEP (PEEPtot) consists of
two components:
1 Extrinsic PEEP (PEEPe) is the pressure
maintained by the ventilator at end-expiration
1 Intrinsic PEEP (PEEPi), also known as auto-PEEP,
is caused by air trapping in the lungs due to
certain pathophysiological conditions or when
too short an expiration time is allowed.
1 Compliance (Compl) measures the stiffness
properties of the lungs and thoracic wall. When
the lungs expand easily their compliance is high.
The compliance is calculated by dividing the
B e gi n n er ’s G ui de 51
 amount of volume change in the lungs by the Typical values greatly vary depending on the
pressure change of the inhaled gas. patient and his condition. In anesthesia, where
patients often have healthy lungs, start-up settings
∆V = volume increase in ml are chosen based mainly on the patient’s
Compliance = demographics. In critical care, where mechanical
∆P = pressure increase ventilation is widely used to improve patient’s
(Pplat-PEEPtot) in cmH2O deteriorated oxygenation, ventilator parameters are
often manipulated and the range of measured
Compliance tells the clinician about the spirometry values is wide.
efficiency of patient’s ventilation. It guides in In the following chart (table 6) typical range of
finding the optimal ventilator settings. values for an adult patient are listed.
1 Airway resistance (Raw) is the impedance to gas
flow in the airways. Airway resistance is Anesthesia Critical Care
clinically important treating asthmatic patients, TVexp 7-10 ml/kg 5-10 ml/kg
RR 8 -12/min 8 – 12/min
whose airway resistance may vary rapidly. It is
I:E 1:2 2:1 - 1:4
also used for measuring the reactivity of the
Ppeak 15 cmH2O < 30 cmH2O
airway, and the response to treatment with
Pplat 12 cmH2O < 23 cmH2O
certain pulmonary drugs.
PEEPe 0-5 cmH2O 3 – 10 cm H2O
1 V(1.0) expresses how much of the total expired
PEEPi 0 cmH2O 0 – 6 cmH2O
volume comes out during the first second of
Compl 35-60 ml/cmH2O 40 - 60 ml/cmH2O
expiration.
Raw 10 cmH2O/l/s 5 – 15 cmH2O/l/s

Measuring lung mechanics continuously,
breath-by-breath, is called dynamic spirometry. In
certain critical care ventilators, it is possible to apply
inspiratory and expiratory holds, i.e. occluding the
airway for 3-5 seconds at end inspiration and
expiration. This is done to derive static spirometry
values for Pplat, Compl, and PEEPi. Static
conditions allow airway pressures to equilibrate
before measurement and may provide more
accurate values.
Table 6. Typical spirometry values for an adult.
Graphical Information
Curves and loops appear on screen combined with
the numeric, quantitative values.
The pressure curve is a useful tool with which
to track the characteristics of the delivery of gas
from the ventilator and the effect this delivery has
on airway pressures. A pressure measurement is
transcribed into a curve.

cm H2O

15 1
2
4 5
5 3
0

Picture 43. The pressure curve.

In the above picture (picture 43):
(1) The ventilator delivers a breath to the patient by
exerting a positive pressure. Throughout this part
of the inspiratory phase, the pressure at the
airway is increasing at a constant rate until
Ppeak has been reached.
(2) If an inspiratory pause is applied, there is a
period after Ppeak when there is no gas flow.
This remains a part of the inspiratory phase and
is known as Pplat. The pressure drop is due to
gas distribution within the lungs.
(3) During expiration the pressure drops back to
baseline and the lungs return to their deflated
state. The pressure in the lungs will fall back to 0,
or atmospheric pressure, unless PEEP is applied.
(4) The total area under this curve is known as the
mean airway pressure or Pmean.
(5) With the application of PEEP, the overall shape
of the pressure curve remains unchanged.

52 Be g i nne r ’s Gu i d e
 The flow curve and the pressure curve are
very closely related. This is because changes in the
characteristics of the delivered breath or changes in
patient lung mechanics can induce changes in both
A B C
cm H2O
1 delivered (volume controlled ventilation) or the
1 2
2 preset pressure/time has been achieved (pressure
3 3
4 4
p
l/min
3 lungs due to the elastic forces of the lung /
3
o 2 4 2
V
1 1
A = inspiration time
B = pause time
C = expiratory time
Picture 44. The pressure curve and the flow curve.
Spontaneous
breath
Vol
Paw
Picture 45. Pressure/volume loops.
Flow and pressure curves show the parameters
in successive breathing cycles over time. The
graphical loops displayed by Patient Spirometry
also show pressure and flow but in relation to
volume, not time. Basically, the loops provide almost
all the necessary information which was discussed
in previous chapters. An experienced clinician is
able to see the status of the patient’s lung mechanics
at a glance.
From a pressure/volume loop (picture 45), four
phases of ventilation can be seen as follows:
the pressure and the flow curves. Like the pressure
curve the flow curve (picture 44) can be divided into
four distinctive parts:
(1) During inspiration, flow is either constant or
decelerating until the preset volume has been
controlled ventilation).
(2) An inspiratory pause is shown as a period of no
flow on the flow curve.
(3) Expiration begins with rapid emptying of the
thoracic system. The flow gradually slows down
4
as the lungs empty and as areas of the lungs with
higher resistance or damage begin to empty. The
flow returns to zero at the end of the expiratory
phase. This corresponds with airway pressure
returning to baseline (4).
Controlled Controlled
breath breath with PEEP
Vol Vol
1 Paw PEEP Paw
(1) Beginning of inspiration: volume is lower at this
point, although pressure increases rapidly, as the
resistance of ventilator tubing and the
endotracheal tube as well as the surface tension
of alveoli must be overcome before flow can
start.
(2) Inspiration: gas flows more freely into the lungs,
there are larger volume changes for lower
pressure changes.
(3) Pause: pressure decreases into a plateau while
gas diffuses into the alveoli.
B e gi n n er ’s G ui de 53
(4) Expiration: both pressure and volume decrease Since the loop is showing the relation between
as lungs deflate (baseline). pressure and volume, the slope of the loop is an
(5) If PEEP is applied, the lungs return to a baseline indicator of compliance.
pressure which is above atmospheric pressure.

V V
l/min 2
l/min
3
V V
ml ml
1a
1b

1a Constant flow
1b Decelerating flow

Picture 46. Flow/volume loops.

The flow/volume loop (picture 46) provides a
clear view of the flow relating to volume during
inspiration and expiration:
(1) Inspiratory phase: gas flows from the ventilator
to the lungs. The way in which the ventilator
delivers the flow will be distinguishable.
(2) Expiratory phase: during expiration flow
depends on patient airway and lung
characteristics. Thus, the shape of a flow volume
curve during expiration will vary according to
presence or absence of disease states, for
example during increased airway resistance.
(3) If air is trapped in the lungs (PEEPi), expiratory
flow will not reach the baseline.

3.1.2 Carbon Dioxide

Detecting and measuring the CO2 of inspired and in critical care. It can provide valuable information
expired air has become a standard in taking care of on the patient’s ventilation, circulation, and
artificially ventilated patients both in anesthesia and metabolism.

%
CO2 5 C ET
O FI 0.0
-0
2 5.0 RR 15/min
%
O2 21
O ET
2
16 F I 21
16 F I - ET 5.0
%
Enf 5.0 E ET
2.0
n
f
2.3 F I 3.0
0 MAC 0.8

Picture 47. Monitoring airway gases. CO2 waveform.

54 Be g i nne r ’s Gu i d e
 An analysis and understanding of the CO2
waveform (capnogram) shape and end-tidal CO2
(EtCO2) measurement (picture 47) are very
important in the early diagnosis of adverse events
such as hypo-/hyperventilation, esophageal
intubation, circuit disconnection or defective
breathing systems.
The capnogram can be analyzed for its
1 Height: depends on the EtCO2 concentration
(Normal range: 4.8 - 5.7% or kPa, 36 - 43 mmHg)
1 Baseline: normally should be at zero. Higher
values indicates rebreathing of CO2.
1 Shape: there is only one normal shape for the
capnogram. Any change in the shape should be
investigated.
AB C D E
inhalation exhalation inhalation
Picture 48. Capnogram waveform.
In the picture 48:
A-B: Inspiratory baseline with ending of inspiration
and beginning of expiration. Elevations of the
baseline indicate rebreathing of CO2.
B-C: Rapid increases in CO2 concentration as
expiratory gas comes from anatomical dead
space and then from the alveoli. The shape
varies with the duration of expiration: the less
steep this part of the curve, the more prolonged
the expiratory phase. This can be due to a
kinked endotracheal tube, obstruction in the
airway or acute bronchospasm.
C-D: An alveolar plateau is reached when the
exhaled gas originates entirely from the alveoli.
The end-tidal CO2 concentration is measured at
the end of this plateau. Factors which can
change the shape of the alveolar plateau
include patient breathing against the ventilator,
obstruction in the airway or increased airway
resistance, and mechanical irritation of the
abdominal area by the operating surgeon.
D-E: When inspiration starts, the capnogram rapidly
falls towards the baseline.
End-tidal CO2 is a non-invasive, breath-by-
breath indicator of metabolism (production of CO2),
circulation (transport of CO2) and ventilation
(elimination of CO2). EtCO2 is a useful parameter for
defining the efficiency of mechanical ventilation,
assessing adequacy of cardiac output, and a sudden
increase in metabolism. It may also assist in the
correct positioning of the endotracheal tube. Besides
the numerical value of EtCO2, the capnogram
usually helps to determine the actual reason for
abnormal EtCO2 values. Therefore, the EtCO2 value
should always be evaluated with simultaneous
capnogram analysis.
Under normal circumstances, EtCO2
corresponds closely with the arterial partial
pressure of CO2 (PaCO2). The normal physiological
difference between EtCO2 and PaCO2 is 2-5 mmHg.
Datex-Ohmeda’s CO2 measurement is based on
the infrared principle which is fast and allows
breath-by-breath monitoring with display of the
capnogram. The same infrared “bench” is also able
to measure N2O and anesthetic agents.

TASKS 3.1 Monitoring Ventilation

Q1 What is spirometry used for? ________________________________________________________________
__________________________________________________________________________________________

Q2 In what form can the spirometry information be delivered? ______________________________________

__________________________________________________________________________________________
Q3 What do the following abbreviations mean?
I:E _______________________________________________________________________________________
Ppeak ____________________________________________________________________________________
PEEP _____________________________________________________________________________________
Compl ____________________________________________________________________________________
Raw ______________________________________________________________________________________

B e gi n n er ’s G ui de 55
Q4 Looking at the Pressure/volume loop, you notice that in the beginning the pressure increases rapidly,
but the volume remains low. Why?
__________________________________________________________________________________________
__________________________________________________________________________________________

Q5 CO2 waveform is called _____________________________________________________________________

Q6 EtCO2 gives valuable information about what three functions of the body? _________________________
__________________________________________________________________________________________

Q7 What conditions can change the shape of the alveolar plateau phase in a capnogram? _______________
__________________________________________________________________________________________
__________________________________________________________________________________________

3.2 Monitoring Oxygenation

Monitoring inhaled oxygen and patient ventilation methods of monitoring tissue oxygenation: arterial
tells that the oxygen probably reaches the lungs. It blood gases, pulse oximetry, and mixed venous
does not, however, give information about oxygen oxygen saturation (see picture 51).
being delivered to the tissues. There are several

3.2.1 Patient Oxygen

The Patient Oxygen measurement offers actual
inhaled and exhaled oxygen values at the patient’s
airway, breath by breath.
A continuous adequate supply of oxygen is
necessary to sustain life. The oxygen reserves of the
body are small when compared to those of carbon
dioxide. Thus, cutting or impairing the O2 supply
will rapidly cause permanent damage. Some tissues
can do without oxygen for hours, but the brain may
be permanently damaged after a few minutes
without O2.
The standard oxygen monitor in a ventilator
can measure the oxygen content of the gas mixture
that leaves the ventilator, FiO2 (fraction of inspired
oxygen). This is a minimum requirement of
international standards. With high fresh gas flow,

%
CO2 5 C ET
O FI 0.0
-0
2 5.0 RR 15/min
%
O2 21
O ET
2
16 F I 21
16 F I - ET 5.0
%
Enf 5.0 E ET
2.0
n
f
2.3 F I 3.0
0 MAC 0.8
Picture 49. Monitoring airway gases. O2 waveform.

56 Be g i nne r ’s Gu i d e
good luck, and flawless connections between the
ventilator and the patient airway, the FiO2 is actually
inhaled by the patient. But tubes, hoses, and
connections have been known to leak and the
standard FiO2 measurement offers no control over
breathing system integrity. In a breathing system
with low fresh gas flows, it is all the more important
to measure O2 at the airway.
Monitoring inhaled and exhaled oxygen
amount on each breath enables the control of both
3.2.2 Pulse Oximetry
Pulse Oximetry (SpO2) is a non-invasive method of
estimating the oxygen saturation of arterial blood. It
is a widely used method of monitoring tissue
oxygenation. It is “the fifth vital sign” in patient
monitoring (HR, B/P, RR, Temp, SpO2). It is a simple,
cost-efficient, non-invasive, and reasonably accurate
and rapid method to estimate the oxygen saturation
Pleth 5
Picture 50. Plethysmographic waveform.
The Principle of SpO2 Measurement
Pulse oximeters combine three technologies to
determine and display an arterial oxygen saturation
measurement: spectrophotometry, plethysmography
and microprocessor-based instrumentation. Pulsatile
arterial blood flow is detected by optical
plethysmography, a technology that displays a
waveform from pulsatile arterial blood.
If the displayed pulse waveform is in real time,
clinicians can assess whether the displayed
saturation level is based on true arterial blood flow
or on artifact or interference by observing the shape
of the waveform. Verifying the shape of the
waveform assures the clinician that the major
requisite for pulse oximetry monitoring has been
met, i.e. the oximeter is measuring a pulsating
arterial tissue bed.
the patient’s lungs and the breathing circuit
(ventilator and connections), thus exceeding the
minimal standard requirements and adding to
patient safety. The Datex-Ohmeda paramagnetic O2
sensor is fast enough for a breath-by-breath
measurement of O2 which allows a simultaneous
display of FiO2, EtO2 (end-expiratory oxygen or end-
tidal oxygen), I-EO2 (the difference between
inspiratory and expiratory values), and the oxygram
(picture 49).
of arterial blood (SaO2), i.e. the ratio of oxygen
carrying hemoglobin (O2Hb) to the total
hemoglobin:
SaO2 = O2Hb
O2Hb+Hb
S %
p
0
97
2
The actual measurement of arterial oxygen
saturation is done by spectrophotometry, a
technique that quantifies the amount of transmitted
light. The pulse oximeter sensor transmits two
wavelengths of light, red and near-infrared, through
a tissue bed (finger, toe, earlobe, etc.), to measure
the relative concentrations of oxyhemoglobin and
deoxygenated hemoglobin in pulsatile arterial
blood. Oxygenated and deoxygenated hemoglobin
each absorb light in different quantities.
With SpO2, we can get both the numerical
estimation of arterial oxygen saturation, and the
plethysmographic waveform (picture 50) indicating
the pulsating blood volume in the peripherial artery.
The normal range of SpO2 at sea level is 97-100%.
When we rise above from sea level the normal SpO2
values will decrease.
B e gi n n er ’s G ui de 57
 An adequate degree of arterial oxygen
saturation guarantees neither the release of oxygen
to the tissues nor the ability of the tissues to utilize
it. The SpO2 value is only an estimation of the
amount of oxygen available for tissue oxygenation.
highly elevated in smoke inhalation patients, and
heavy smokers. Currently the SpO2 measurement
does not measure the presence of DysHb or COHb
and thus overestimates oxygen saturation.

Limitations of Method
The basic limitation of the SpO2 method is that if
peripheral blood circulation is limited (poor
perfusion), there is no detectable pulse and
consequently, no signal.
Another limitation arises because only two
wavelengths are being used in the measurement.
Thus, only two forms of hemoglobin can be
detected. Blood, however, also contains other
hemoglobin fractions (DysHb), although in small,
usually constant quantities. The carboxyhemoglobin
(COHb) fraction is normally small, but may be
External Interference
Motion artifacts, electrosurgery, and pulsating light
may also interfere with SpO2 measurement. The
integrity of the real time pulse waveform may serve
as an indicator of the absence of external
interference.
Despite its limitations, pulse oximetry has
proven an invaluable help in assessing the patient’s
oxygenation status in various environments:
operating room, critical care unit, recovery and the
ward. It is successful because it meets the
requirements of simplicity, non-invasiveness,
continuity, and transportability, while providing
reasonable accuracy.

3.2.3 Mixed Venous Oxygen Saturation

Mixed venous oxygen saturation (S– vO2) is the

difference between arterial oxygen saturation
delivered to the tissues and their oxygen
consumption. It is measured in the pulmonary
artery with a special pulmonary artery catheter.
“Mixed venous” indicates that blood from all veins
77
coming from different organs, as well as blood from
the superior and inferior vena cava, has been mixed
99
(picture 51). S–
vO2 thus represents a global measure
of the total body system. SvO2 75
SaO2
In low- to medium-risk situations the
estimation of oxygen saturation of arterial blood by
SpO2 reflects the sufficient oxygen delivery to the
organs and tissues. With critically ill patients, 80 97
intermittent cardiac output and arterial blood gas
65
measurements provide the clinician with a fuller
picture of oxygen supply, but there is still a need to
relate the oxygen supply to oxygen demand and
90
consumption.
The amount of oxygen returning to the right
side of the heart depends on the inspired oxygen 70
amount, the oxygen amount in arterial blood, the
transporting capacity of blood (presence of
SpO2
hemoglobin and good cardiac output) and how
much oxygen the tissues have used (see picture 46).
The normal range for S– vO2 is 60 - 80 %. If the values Picture 51. Organs use different amounts of oxygen.

58 Be g i nne r ’s Gu i d e
are abnormal, the clinician checks all the
components (oxygenation, hemoglobin amount,
cardiac output, tissue metabolism) to find the reason
behind the abnormal readings.
S–
vO2 can be monitored continuously with the
pulmonary artery catheter which contains fiber
optic sensors. The measurement principle is the
same as with pulse oximetry, except that while SpO2
is based on absorption of light, S–
vO2 is based on the
reflection of light. The same limitations due to
carboxyhemoglobin apply.
Mixed venous oxygen saturation can also be
measured from the venous blood returning from the
brain (SjO2). The measuring is done with a special
jugularis bulb catheter which is inserted into the
jugular vein. The obtained value reflects the balance
of oxygen delivery and consumption in the brain.

TASKS 3.2 Monitoring Oxygenation

Q1 What does Patient oxygen measure? __________________________________________________________

Q2 What are the benefits of monitoring Patient oxygen at the airway instead of at the ventilator outlet?
__________________________________________________________________________________________
__________________________________________________________________________________________

Q3 Pulse oximetry is a method of estimating ______________________________________________________

Q4 What does observing the plethysmographic waveform help to assess? _____________________________

__________________________________________________________________________________________

Q5 What limitations does the SpO2 measurement have? ____________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

Q6 What does S–
v O2 measure? __________________________________________________________________

Q7 What does the term “mixed venous” mean? ____________________________________________________

__________________________________________________________________________________________

Q8 What components affect the oxygen amount returning to the right side of the heart? ________________
__________________________________________________________________________________________
__________________________________________________________________________________________

3.3 Monitoring Metabolism by Gas Exchange

Pulmonary gas exchange measurement means
.
monitoring of oxygen consumption (VO2) and carbon
.
dioxide production (VCO2). Using them, it is
possible to calculate the respiratory quotient (RQ)
which is the ratio between CO2 production and O2
consumption, and energy expenditure (EE) which
means how many calories of energy is used by the
patient.
The clinical applications of gas exchange
monitoring range from assessment of energy
requirements and response to nutrition, to
comprehensive analysis of ventilation and oxygen
transport in patients with complex cardiovascular
problems.
Calorimetry means measurement of energy
expenditure. Heat loss from the body which

B e gi n n er ’s G ui de 59
indicates the energy expenditure, can be directly
measured by whole-body or direct calorimetry. The
patient is placed in a sealed, insulated, box-like
chamber, and the heat produced is removed by
water circulating through the coils inside the
chamber. Direct calorimetry is a cumbersome and
slow process and seldom is used.
Indirect calorimetry is based on the
measurement of pulmonary gas exchange which in
a steady state, corresponds to the release of energy
from the body. Every time the homeostasis of a
patient is changed, the steady-state condition is
disrupted, and a certain period of time has to pass
before a new steady-state is re-established. This is
very important when the measurement is made over
a short period. In continuous measurement, it is
possible to obtain average results over longer
periods, and then the effects of varying steady-state
are eliminated.
Measurement Principle
Traditionally, indirect calorimetry has been
performed by collecting expired air into a Douglas
bag during a set period of time, and then analyzing
the gas concentrations and volume. Newer methods
use gas sensors and flow/volume transducers,
automatically and continuously measuring O2
uptake and CO2. Most of the existing measurement
devices are either stand-alone monitors or
incorporated in critical care ventilators. Some of
them are designed specifically for exercise testing.
. .
Respiratory quotient (RQ = VCO2 / VO2) gives a
rough idea about the energy source patient is using,
if it is carbohydrates, fats or proteins (table 7).
RQ Energy / g
>01.0>0 overfeeding
>01.0>0 carbohydrates 4.31 kcal (glucose)
>00.83> proteins 4.1 kcal
>00.71> fat 9.3 kcal
<00.7>0 starvation
Table 7. Respiratory quotient approximates which substrate
is mainly utilized.
Clinical Applications
Indirect calorimetry has a wide range of
applications both in clinical practice and in
research. The main application aims at optimizing
nutrition so that both malnutrition and overfeeding
can be prevented.
In malnourished patients, the respiratory
strength decreases leading to difficulties in weaning
the patient from the ventilator. During overfeeding,
the body increases CO2 production, leading to
increased respiratory demand. The patient groups
whose caloric needs differ most from the estimation
include patients with burns, severe infections, and
neurological trauma or disorders.
In a wider perspective, the monitoring of
oxygen consumption has additional applications in
the assessment of the overall oxygenation status of
the patient. In anesthesia, promising application
areas are all major surgeries causing major blood
.
loss or volume changes, where continuous VO2
could be used to estimate adequacy of circulating
blood volume or the effects of therapeutic
interventions. In major organ transplantation, it is
.
valuable to follow by VO2 measurement the process
of the new organ becoming a part of circulation.

TASKS 3.3 Monitoring Metabolism by Gas Exchange

Q1 What does indirect calorimetry mean? ________________________________________________________
__________________________________________________________________________________________

Q2 Respiratory quotient (RQ) approximates ______________________________________________________

__________________________________________________________________________________________

Q3 What is indirect calorimetry used for in clinical practice? _______________________________________

__________________________________________________________________________________________

60 Be g i nne r ’s Gu i d e
3.4 Monitoring Blood Circulation
3.4.1 Blood Pressures
Blood pressure is the pressure exerted by blood
against the walls of the blood vessels. It is expressed
in millimeters of mercury (mmHg).
Resistance to flow depends on the length and
the diameter of the arteries and veins, and the
viscosity (thickness) of blood (table 8). The higher
the resistance of the vessels, the more the pressure
will drop between two given points along the route.


Change


Resistance
Length


Diameter
Viscosity



Table 8. The effects of the changes of length, diameter and
viscosity on resistance.
Systolic, Diastolic and Mean Pressures
If the heart were a linear pump, delivering a steady
and continuous flow of blood into circulation, then
the pressure exerted by the flowing blood against
the walls of the blood vessels would be stable
regardless of the absolute value. However, the heart
delivers blood with each contraction, and thus
creates pulsatile flow and pulse pressures (picture
52).
mmHg
120
systolic
mean
60 diastolic
0
Picture 52. The heart creates a pulsatile pressure with each
contraction.
The heart’s contraction is equal to a situation
where volume of vessels decreases while the volume
of fluid in the system remains the same. Thus,
pressure increases. In physiology, the highest
pressure is called systolic pressure and it closely
equals the highest pressure generated by the left
ventricle at the end of cardiac cycle.
The relaxing heart increases its volume and
thus the volume of the vessels increases. Therefore,
pressure decreases. The lowest pressure during this
phase is called diastolic pressure. The mean
pressure is a calculated, average pressure in a vessel
over time.
Non-Invasive Blood Pressure (NIBP) Measurement
In the non-invasive method, an artery, usually in the
arm, is occluded by inflating a cuff that has been
applied around the upper arm. When the cuff is
then gradually deflated, the pressure in the artery
becomes equal to the cuff pressure. With further
deflation the blood flow in the artery will return.
When the blood rushes through the small opening
in the artery, it flows turbulently and creates distinct
pressure waves. These can be listened to using a
stethoscope or these waves can be measured with a
pressure transducer. The systolic reading is obtained
at this cuff pressure.
Further deflation of the cuff will eventually
fully open the artery and the blood flow will
become laminar. The point where the distinct
sounds, the Korotkoff sounds, will disappear
indicates a fully open artery. The diastolic reading is
obtained at this cuff pressure. Non-invasive blood
pressure monitoring is best suited to low and
medium-risk situations as it is not continuous.
Invasive Blood Pressure Measurement
Invasive blood pressure measurement is done via a
catheter inserted into an artery or a vein. The
catheter is connected to tubing filled with saline.
Because of the relative incompressibility of water
the fluid filled tubing will transmit the pressure
from the catheter tip to the transducer.
A pulmonary artery catheter is used to
measure pressures in a central vein (CVP) and
pulmonary artery (PAP, PCWP). The catheter is most
commonly inserted in the jugular vein of the neck.
At the tip of the catheter there is a small balloon.
When the balloon is inflated, it will cause the
catheter to float in the blood stream via the right
atrium to the right ventricle and eventually into the
pulmonary artery (picture 53). When the catheter is
B e gi n n er ’s G ui de 61
.
in the pulmonary artery, inflating the balloon will Central Venous Pressure (CVP), (Mean 1 - 10
occlude the artery, stopping the blood flow in it. mmHg)
Thus the pressure at the catheter tip equals the CVP can be measured through a catheter inserted
pressure on the pulmonary veins, and the left into superior vena cava. CVP closely reflects the
atrium. It is often used to estimate the filling pressure in the right atrium and depends on several
pressure of the left ventricle. factors: the patient’s volume status (hypovolemia/
hypervolemia), the right ventricle performance, and
resistance of pulmonary circulation. CVP also
RAP RVP PA PCWP40
mmHg reflects the right ventricle’s ability to pump the
PA blood returning from systemic circulation, to
PCWP
20
pulmonary circulation. This pumping capacity often
RA corresponds to that of the left ventricle.
CVP is sometimes referred to as right atrial
RV 0
pressure (RAP). The obtained CVP value should be
matched with other information about the patient’s
blood circulation. CVP reading alone can be
Picture 53. The position of the pulmonary artery catheter and misleading.
the different pressure waves.

Monitoring invasive blood pressure offers Pulmonary Artery Pressure (PAP), (30/15 mmHg)
continuous, beat-to-beat information on the patient’s
The pulmonary artery pressure is the lung’s
cardiovascular status. It has become a widely used
equivalent of systemic arterial pressure and gives
method in medium- to high-risk surgery situations,
information on the pulmonary circulation. Like
and in the ICU.
arterial blood pressure, it is pulsatile. The systolic
value, PASP, reflects the pressure generated by the
Systolic and Diastolic Arterial Pressure, 120/80 contraction of the right ventricle and the diastolic
value, PADP, reflects the resistance of the
The systolic pressure generated by the contracting
pulmonary circulation.
heart reflects the oxygen demand of the heart itself.
The stronger the contraction, and the pressure, the
more oxygen is consumed. It is also important that Pulmonary Capillary Wedge Pressure (PCWP),
the systolic pressure is high enough to overcome the (Mean 5-15 mmHg)
vascular resistance of systemic circulation. A
The PCWP is measured from the right side of the
persistently elevated systolic pressure indicates
heart, from the pulmonary artery. When the
increased cardiac output or decreased distension of
pulmonary artery catheter is wedged, the artery is
the arteries, and is harmful to the heart muscle
occluded (closed, blocked) with a balloon. The
because of the constant high workload.
pressure beyond the balloon is measured. This
The diastolic pressure which remains in the
pressure is called PCWP or pulmonary artery
arteries during the resting phase of the heart,
occlusion pressure (PaOP).
reflects the peripheral resistance. Myocardial
There are no valves in the pulmonary
perfusion depends on the diastolic blood pressure,
circulation, so PCWP measures the pressure in the
as most of the perfusion occurs during diastole. Too
left atrium. While the mitral valve is open, at the
low diastolic pressure endangers oxygen delivery to
end of the left ventricular diastole, PCWP also
the heart muscle, while too high diastolic pressure
reflects the pressure in the left ventricle (Left
indicates constriction in the peripheral circulation.
Ventricular End-Diastolic Pressure = LVEDP) which
is an indicator of the left ventricular preload.
Mean Arterial Pressure (MAP), (60 - 90 mmHg)
Mean arterial pressure reflects the driving pressure
pushing blood into the organs. When measured
continuously, it normally fluctuates less than
systolic pressure.

62 Be g i nne r ’s Gu i d e

3.4.2 Cardiac Output
Cardiac output is defined as the amount of blood
pumped by the heart in one minute (C.O. = HR x SV).
Changes in cardiac output reflect changes in the
factors that affect either the stroke volume or the
heart rate e.g. temperature, blood volume, or
condition of the heart muscle.
Together with pulmonary capillary wedge
pressure measurement, cardiac output assists in
evaluating heart’s left ventricular function. The
normal value for C.O. is 3-7 L/min., and depends on
body size. Cardiac output can be divided by the
patient’s body surface area (BSA) to get a cardiac
index (C.I.). It measures the cardiac output in
proportion to the patient’s body size.
The Thermodilution Method
Cardiac output can be measured using a
thermodilution method. For this a pulmonary artery
catheter is necessary. It has at least two lumens, one
opening into the right atrium and one opening into
pulmonary artery. It also has a temperature probe at
the distal end (in the pulmonary artery).
A specific amount of solution with a
temperature significantly lower than body
temperature is injected into the right atrium. This
solution cools down the blood which is ejected from
the heart into the pulmonary artery. The
measurement concept is easily understood by
3.4.3 Gastric Perfusion
If we feel anxious, are scared, or some stimulus in
our surroundings changes very fast, the blood from
our stomach and intestines (gastrointestinal tract) is
redistributed to the vital organs. A healthy person
can experience this reaction many times a day and
the blood returns back to the gastrointestinal tract
(GI tract) automatically when the threatening
situation is over.
This is also the case in critical conditions.
Because the GI tract is not so important in such a
situation, the blood is transferred to organs that are
essential for survival, such as brain, heart, and
muscles. For a critically ill person the redistribution
analogy: if we pour the same amount of cold milk
into a small cup of hot coffee and into a big cup of
hot coffee the small cup will cool down more. The
temperature is measured distally in the pulmonary
artery and plotted over time (picture 54).
Change of
temperature ˚C
- 1,0
- 0,5
A
0
time
Picture 54. The thermodilution curve.
TB – TI
C.O. = VI x x K, where
A
VI = volume of injectate
T B = temperature of blood
TI = temperature of injectate
A = area under temperature curve
K = computation constant, catheter specific
Thus it is important to know the exact values
for VI, TB and TI, because inaccurate values will
cause an error in the cardiac output value. Area A is
measured by the monitor.
of blood lasts longer increasing the risk of tissue
damage and organ dysfunction (picture 55).
The stomach and intestines are the first organs
to suffer from any changes in blood flow, and the
last to recover when the situation normalizes. The
GI tract plays an important role in the development
of dangerous diseases like sepsis and Multiple
Organ Dysfunction Syndrome (MODS). Also, the
stomach is quite easy to access for measurement.
Blood flow brings oxygen to the lining of
stomach and intestines and removes carbon dioxide
from them. So when the blood flow is not adequate
the CO2 starts accumulating in the GI tract. This can
B e gi n n er ’s G ui de 63
 hypovolemia
cardiac failure MOF

redistribution
of blood flow

hypoperfusion vicious
PgCO2 circle
tissue
damage

mucosal
disruption
sepsis
endotoxin
and bacteria
translocation cytokine
release

Picture 55. The vicious circle.

be measured with gastric tonometry. Gastric Tonometer

Stomach
tonometry (PgCO2, PrCO2) measures CO2 in the balloon
Gastrointestinal
stomach in the gastric mucosa. This provides lumen
information of the adequacy of gastric perfusion. CO 2

The Measurement of PgCO2
To measure gastric tonometry, a special tonometry
catheter is inserted into the stomach (picture 56). It
resembles, and also works as, a nasogastric tube.
However, the catheter has a gas-permeable silicone
balloon in the end.
Carbon dioxide is a freely diffusible gas that
equilibrates between the gastric mucosa and the
balloon. The monitor infuses air into the catheter
balloon and draws a sample every 10 minutes. It
analyses the sample automatically with an infrared
sensor and displays the PgCO2 value. In a normal
situation, PgCO2 is slightly above arterial pCO2. But
rather than looking at the PgCO2 value, it is
recommended to compare it with either arterial
pCO2 or with end-tidal CO2.
CO 2
Gastric mucosa
CO 2 Gastric muscularis
CO 2
CO 2 CO 2
Arterial blood supply
Picture 56. Tonometry catheter in place.
Gastric tonometry is mainly used during major
surgery or in critical care for patients suffering from
cardiogenic or septic shock, severe acute respiratory
failure, severe acute pancreatitis, major burns, or
trauma. Gastric tonometry provides unique
diagnostic information which enables early
identification of problems and earlier treatment of
the patient. It can also provide a complementary
end-point for resuscitation which improves patient
management.

64 Be g i nne r ’s Gu i d e
TASKS 3.4 Monitoring Blood Circulation
Q1 The unit for blood pressure measurement is ___________________________________________________

Q2 What pressures can be measured with a pulmonary artery catheter? ______________________________

__________________________________________________________________________________________

Q3 MAP stands for ____________________________________________________________________________

Q4 What does CVP stand for and where is it measured at? __________________________________________
__________________________________________________________________________________________

Q5 What does PCWP stand for and what information does it give? ___________________________________
__________________________________________________________________________________________
Q6 Cardiac output = _____________________ x _____________________

Q7 What is cardiac index? ______________________________________________________________________

Q8 What exact values are important to know for C.O. calculation? ___________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q9 Gastric tonometry provides information about _________________________________________________

Q10 PgCO2 is normally ___________________ than PaCO2

Q11 Why is gastric tonometry unique? ____________________________________________________________

__________________________________________________________________________________________

3.5 Monitoring Electrocardiography

ECG Measurement
The heart is a muscle that has an electrical field, in reduce electrical interference. By placing the
which current flows. The electrical activity of the electrodes in different locations, the clinician can
heart can be detected by placing electrodes on the monitor different “views”, called leads, of the heart’s
skin. A lead is composed of two electrodes of electrical activity. The measurement is done from
opposite polarity (bipolar) or one electrode and a negative electrode to positive electrode. The positive
reference point (unipolar). electrode is the “seeing” electrode. The ECG
The electrocardiograph measures and records basically measures three dimensions of electrical
the electrical impulses when they are conducted activity (picture 57):
through different parts of the heart. The electrical
signal generated by the heart is a very weak (from
0.5 to 2 mV) at the skin surface. Therefore, optimum
skin preparation and electrode placement are
important to avoid further weakening and artifacts
of the signal at the skin-electrode interface.
At least two electrodes are needed to detect an
ECG, and a third electrode serves as a reference to Picture 57. Electrocardiograph.

B e gi n n er ’s G ui de 65
1) Direction
The electrical impulses that are going towards the
seeing electrode will cause a positive (upward)
reflection on the ECG waveform and those going
away from the seeing electrode cause a negative
(downward) reflection.
2) Strength (measured in millivolts)
The stronger the electrical impulse, the taller the
reflection on the electrocardiogram.
3) Duration
The ECG recordings are made over time: the
longer the electrical activity continues, the wider
the reflection will be on the waveform.
R L
1 2
3 system adds the possibility to record all the
4 5 6
N F
Picture 58. Standardized locations of the electrodes on the
chest.
Leads
Ten different locations for the ECG electrodes
(picture 58) have been standardized to provide
twelve viewing angles. There are up to 12 leads in
the standard ECG: three bipolar (I, II, III) and nine
unipolar (aVR, aVL, aVF, V1, V2, V3, V4, V5, V6) leads
giving information about current flow in the
different parts of the heart.
Monitoring the heart rate and the rhythm can
be done with only one lead, normally lead II. For
ischemia monitoring and arrhythmia analysis more
leads are used to provide more viewing angles.
Ischemia Monitoring
The ST-segment is of particular interest to the
clinician. Normally, the ST segment is flat at the
level of the isoelectric (base) line. An elevation
66 Be g i nne r ’s Gu i d e
R
P T
QS
Picture 59. ECG with ST-elevation.
above the base line of more than 1-2 mm (0,1 – 0,2
mV), or a depression of more than 1 mm (0.1 mV) is
highly suggestive of ischemia, a lack of oxygen in
the heart muscle (picture 59).
To be able to localize the ischemic area of the heart,
multilead monitoring is required. The 5-lead system
permits recording of all the limb leads (I, II, III, aVR,
aVL, aVF) and one precordial lead (V). The 12-lead
precordial leads (V1 - V6) at once.
Arrhythmia Monitoring
Monitoring arrhythmias means analysing the rhytm
for its
1 Rate: is it too fast (tachycardia) or too slow
(bradycardia)
1 regularity vs. irregularity
1 site of origin: is it a sinus rhythm, atrial, nodal or
ventricular rhythm
1 conduction: are there blocks on the way of the
electrical current
Symptoms of arrhythmia vary from life
threatening situations to minor palpitation and
dizziness. There are three life threatening
arrhythmia (picture 60), where the electrical activity
or the lack of it in the heart does not result in
mechanical pumping of the blood (asystole,
ventricular tachycardia and ventricular fibrillation).
It is important to monitor less dangerous arrhythmia
as well, because there is a risk of deterioration of
the rhythm to a lethal level.
 Asystole

Ventricular
fibrillation

Ventricular
tachycardia

Picture 60. Lethal arrhythmias.

TASKS 3.5 Monitoring Electrocardiography

Q1 What does ECG measure? ___________________________________________________________________

Q2 What dimensions of electrical activity does the ECG measure?

____________________________, ____________________________, and ____________________________

Q3 ST-elevation means ________________________________________________________________________

__________________________________________________________________________________________

Q4 Why is it important to monitor arrhythmias? ___________________________________________________

__________________________________________________________________________________________

B e gi n n er ’s G ui de 67
3.6 Monitoring EEG
When neurons communicate with each other, they
send electrical impulses. These impulses are very
small, but when millions of neurons work together,
their activity can be recorded from the surface of
the body as a voltage (picture 61), much like in ECG.
Electroencephalography (EEG) measures the
spontaneous electrical activity of the cerebral
cortex, i.e. the surface layer of the brain. In a
healthy brain, this activity is quite similar in
different regions of the brain. The EEG has no
constantly occurring pattern like the QRS in ECG,
but can be described as a superposition of various
continuous wave patterns. It is sometimes difficult
to differentiate real brain activity from random
noise.

Picture 61. Monitoring EEG and AEP.

Measurement Principle Interpretation of EEG

The EEG is basically measured like ECG: as a
voltage difference between two electrodes. The
amplitude of the EEG as recorded from the skull
surface is usually in the range of 100 microvolts
(mV), so about one tenth of the ECG amplitude. This
obviously puts some pressure on the measurement
to succeed in noisy environments such as the OR
and the ICU.
The EEG can be characterized by its amplitude
(strength) and, more importantly, by what
frequencies it contains. The EEG has traditionally
been divided into four frequency bands (picture 62).
Beta 13 - Hz

To be able to measure such a small signal, the

first thing to ensure is that the contact between the 7 - 13 Hz
Alpha
electrode and the skin is good. Often the skin is
“prepped” which means that grease and dead cells
4 - 7 Hz
are removed from the skin surface so that the Theta

contact is better. Conductive gel or paste is also used

0 - 4 Hz
to improve the contact. When all the preparations
Delta
are done, there is a way to evaluate the contact by
1 sec
measuring the impedance (the resistance to
alternating currents), between the electrode and the
skin. For good results, impedance should not be Picture 62. The EEG frequency bands. Hertz (Hz) means
higher than five kilo-ohms (kΩ). waves per second.

68 Be g i nne r ’s Gu i d e
 The amplitude and frequency of an EEG can be
analyzed to get a spectrum of the EEG. The
spectrum can be displayed as a curve with the
frequency on the horizontal axis and the power on
the vertical axis (picture 63). The power of the EEG
signal is a calculated value which illustrates the
strength of the signal. The larger the amplitude of
the EEG signal the higher the EEG is in power.
The EEG changes its form due to many things.
The naturally occurring changes result from
changes in the state of consciousness. The fully
awake human who is concentrating on a task has
fast frequencies in his EEG, whereas someone
asleep has slow delta waves in his EEG. During
surgery, changes in the EEG are most often induced
by anesthesia. As in natural sleep, the deeper the
anesthesia, the slower the EEG. Unnecessarily deep
anesthesia can result in a flat EEG. Similar changes
are caused also by inadequate cerebral oxygenation.
If blood flow to the brain decreases or stops for
some reason, the consequence is a very rapid
slowing of the EEG.
A third factor slowing the EEG is body
temperature. In cardiac surgery, the patient’s EEG
may be intentionally brought to isoelectric, flat state
by cooling the patient. This is done because when
the EEG is flat, the brain also consumes very little
oxygen and therefore it is safe to cut the circulation
to the brain for a while.
One reason for admitting the patient to the ICU
is epileptic seizures which often show up as large
amplitude peaks or waves in the raw EEG.
Continuing seizures damage the brain, so the
seizures are suppressed with medication.
Evoked Potentials
Whereas the EEG represents the spontaneous
electrical activity of the brain, it is also possible to
evoke brain activity in certain areas of the brain by
Picture 64. EEG signal with auditory stimulation and the average AEP response.
Power
Delta Theta Alpha Beta
4 7 13 Frequency / Hz 40
Picture 63. The spectrum of an EEG.
stimulating the corresponding sensory system. This
creates Evoked Potentials (EP’s) which are named
according to the related sensory system as:
AEP = Auditory Evoked Potentials
SEP = Somato Sensory Evoked Potentials
VEP = Visual Evoked Potentials
Measurement of evoked potentials requires a
means of stimulating and recording. In practice,
AEP stimulation means delivering clicking sounds to
the ear(s) through a headphone (see picture 61). For
SEP, small electrical pulses are delivered to a
peripheral nerve and for VEP different kind of
images or flashes are shown to the patient.
The evoked potential signal is very small, a
microvolt. Since the spontaneous EEG is running
constantly as well, the signal is hidden under the
EEG and therefore cannot be read directly from the
EEG waveform. Fortunately, we know that the
evoked potential always occurs right after we have
delivered a stimulus. Therefore, the signal is
processed so that the basic EEG signal is removed,
only a small amount around the given signal is
analyzed and result is displayed (picture 64). The
number of given stimuli can range from 100 to
thousands, depending on the situation and the
amount of external noise, how good the response is,
and how much time is available.
1 2 5 10 20 50 100 200 500 1000
B e gi n n er ’s G ui de 69
Interpreting the EP
The different waves in the EP come from different
parts of the nervous pathway, as the stimulus moves
from the brain stem to cortex to be processed and
analyzed in the brain. In AEP, the evoked potentials
appearing in the first 10 ms come from the auditory
nerve and brain stem (brain stem response). The
EP’s, that appear in 10 to 100 ms, come from the
subcortical area (mid latency auditory evoked
potential). The ones coming after that, all the way
up to one second, represent higher processing of the
stimuli done in the cortex (long latency auditory
evoked potential).
The time it takes for a wave to occur after the
stimulation is called latency. When interpreting
evoked potentials, both the latency and the
amplitude of the waves are important. Sometimes
the mere existence or non-existence of certain
waves tells about the functioning of a certain part of
the nervous system.

TASKS 3.6 Monitoring EEG

Q1 EEG provides information about _____________________________________________________________
__________________________________________________________________________________________

Q2 Why is the impedance measured when monitoring EEG? ________________________________________

__________________________________________________________________________________________

Q3 The maximum recommended level of impedance is ____________________________________________

Q4 How can impedance be reduced? ____________________________________________________________

Q5 What may cause changes in EEG? ____________________________________________________________

__________________________________________________________________________________________

Q6 What factors are important in interpreting evoked potentials? ____________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

3.7 Monitoring Adequacy of Anesthesia

Adequate anesthesia is an oblivious and
unconscious state of a patient. It is mainly produced
with anesthetics and analgesics. The necessary
muscle relaxation for the surgery is produced with
neuromuscular blocking agents. To monitor the
effect of the analgesics (pain medication) the patient
is watched for changes in heart rate, blood pressure,
ventilation, and gas exchange. Other physiological
signs of pain include shedding tears and constriction
of peripheral vessels. The effect of the anesthetics
can be monitored with methods derived from EEG,
such as evoked potentials and bispectral monitoring.
The effect of muscle relaxants can be monitored
with NMT-monitoring.

70 Be g i nne r ’s Gu i d e
3.7.1 Inhalational Anesthetic Agents

Inhalational anesthetic agents are volatile (evaporate
rapidly) and are administered by leading the gas
vapor from a vaporizer into the breathing circuit.
The correct and safe administration of inhalational
anesthetics depends on how well the characteristics
and effects of each agent on the human body are
known, and how well their presence in blood can be
estimated.
Monitoring inhalational anesthetic agents
means identifying the given agent and measuring its
amount in the gases that patient is breathing or
being ventilated with. Continuous monitoring of
agent concentration is needed to ensure that the
patient gets the optimal dose of the agent.
Anesthetic agent concentrations are expressed in %
(picture 65).
Monitoring can also show the wash in/out of
the agent, thus making it easier to predict the
moment of emergence from anesthesia. Anesthetic
agents are measured by infrared (IR) spectrometry.
Inhalational anesthetic agents used today are
Halothane, Enflurane, Isoflurane, Sevoflurane,
Desflurane, and Nitrous oxide.

%
CO2 5 C ET
O FI 0.0
-0
2 5.0 RR 15/min
%
O2 21
O ET
2
16 F I 21
16 F I - ET 5.0
%
Enf 5.0 E ET
2.0
n
f
2.3 F I 3.0
0 MAC 0.8

Picture 65. Monitoring Enflurane.

MAC = Minimum Alveolar Concentration

One Minimum Alveolar Concentration (MAC)
means how much of the inhalational anesthetic
agent is needed for 50 % of average 50 year old, 70
kg population not to react to skin incision. It is
needed to equalize the differences (Table 9) in the
strength of different anesthetic agents: 0.75 % of
halothane or 6.0 % of desflurane are needed to
make 50 % of the patients non-responsive to a
standard skin incision.
Unless the effect of anesthetics is monitored, in
clinical practice a MAC greater than 1.0 is
necessary, because the other 50 % of the patients
would still react. Administration of approximately
1.3 - 1.6 MAC prevents movement in nearly all
patients. The MAC is influenced by patient’s age,
weight, disease, other medications and some other
factors that need to be taken into account in the
planning phase of anesthesia.

Halothane Enflurane Isoflurane Sevoflurane Desflurane N2O

MAC (vol-%) 0.75 1.68 1.15 2.0 6.0 104

Table 9. All inhalational anesthetics have different MAC values.

B e gi n n er ’s G ui de 71
 The MAC value shown on the monitor is
calculated by the following formula:
% EtAA % EtN2O
MAC(AA) = ---------------- + -----------------
X(AA) 100
X(AA) is equivalent to one MAC of the used
anesthetic agent in oxygen. It takes into account the
difference of MAC values of the anesthetic agents
and the intensifying effect of N2O on anesthetic
agents.
3.7.2 Muscle Relaxation
If one is punched in the stomach, the abdominal
muscles will contract as a protective reflex. The
same happens in abdominal surgery during the skin
incision or handling of the gut. To prevent this the
muscles may need to be paralyzed with muscle
relaxants during surgery.
Critically ill patients are sometimes paralyzed
to improve the ventilation, to decrease the work of
breathing, or to decrease the metabolic rate and
oxygen consumption. Whenever neuromuscular
blockers are used, it is recommended to monitor
their effect with neuromuscular transmission
monitoring (NMT)(picture 66).
A muscle gets an order to contract as a
chemical message generated by an electrical
impulse from a nerve. The chemical transmitter
between the nerve and the muscle is called
Picture 66. Measuring neuromuscular transmission with a MechanoSensor.
72 Be g i nne r ’s Gu i d e
Agent Identification
Identification of volatile agents helps to detect
misfilled vaporizers, vaporizer contamination and
situations in which two anesthetic agents are
present at the same time. It also eases the daily
routine in the operating room. It is not necessary to
manually select the agent because the monitor
automatically identifies it at the moment of
detection.
acetylcholine. Normally it binds to the receptors on
the muscle side, producing depolarisation and
muscle contraction.
Neuromuscular blocking agents (NMBA’s)
affect transmission of the electrical impulse, and
that is why monitoring of the blockade is performed
by providing an external electrical impulse to a
nerve, usually in the hand, and observing or
measuring how the muscle responds to it (picture
66). The smaller the response, the more paralyzed
the patient is.
Neuromuscular blocking agents prevent the
normal transmission of an impulse from the nerve
to the muscle. They can be divided into two groups
on the basis of their action on the neuromuscular
junction. Depolarising agents (succinylcholine)
rapidly block the effect of acetylcholine by
occupying the receptor sites for a short period, while
non-depolarising agents such as vecuronium
compete with acetylcholine for the receptor sites
and produce a longer lasting paralysis.
The two types of neuromuscular blockers –
depolarizing and non-depolarizing – affect the
muscle response in different ways. The more
commonly used non-depolarizing drugs cause a fade
in the responses for stimuli given with short
intervals, and the slope of the fade is related to level
of blockade. The most common monitoring mode is
to give four stimuli to a nerve (Train-of-Four, TOF),
and then to measure the fade in the responses. The
fade is expressed as the Train-of-Four Ratio (TOF%).
It is the ratio of the fourth muscle response to the
first one (picture 67). Depolarizing drugs simply
cause a reduction of amplitude in the response to
stimulation. The level of the block is seen in the
height of the four responses.
The neuromuscular blockers do not have any
central depressing effects. They do not cause
unconsciousness. Thus, a patient may feel pain or
fear unless adequate analgesia and sedation/
hypnosis is ensured.
The effect of the neuromuscular blockers is
terminated through metabolism or by giving an
antidote, a reversal agent. The restoration of normal
3.7.3 Depth of Anesthesia and Sedation
The patient is given hypnotics, inhaled anesthetic
agents, and sedatives to produce unconsciousness
and amnesia during an operation or a treatment.
The effects of medications are different on each
individual patient. To find an optimal dose of the
optimum anesthetic agent is a challenge the
anesthetist faces every day.
Overdosing sedatives and hypnotics increases
the chance of side-effects of the used medication,
producing cardiovascular lability, and postoperative
nausea and vomiting. Too deep anesthesia will
prolong awakening and postoperative recovery.
Under-usage of anesthetic agents would result in
patient’s awareness during surgery.
Patients in the ICU may need sedation to adjust
to being hooked to a ventilator, and when they are
having different procedures done. Sometimes they
Stimulus
Depolarizing
block
TOF Count = 4
1 234 1 23 4
75 - -
Fade
Non-
depolarizing 15 - - - - -
block TOF Count = 3
1 234 1 23
TOF% = 15 x 100% = 20%
75
Picture 67. The different effects of depolarizing and non-
depolarizing blockers on the NMT monitoring.
muscle function (including breathing) is often
wanted to return quickly, and the process is
hastened by administering reversal agents of non-
depolarising muscle relaxants.
NMT monitoring helps to optimize the
administering of neuromuscular blocking agents
according to patient’s individual needs. Patient’s
recovery from anesthesia can also be predicted.
NMT monitoring helps to determine when patient
can be extubated safely, and respiratory
complications after extubation due to the effects of
NMBA’s can be prevented.
may be paralyzed to improve oxygenation or to
decrease the oxygen consumption. Critical care
patients may have several conditions which affect
their level of consciousness and the metabolic rate
of sedative medications. It can be difficult to find
the optimal dosage of sedation to each individual
patient.
Receiving too much sedation may affect
patient’s hemodynamic stability and slow down
patients’ recovery in the ICU. Over-sedation will
complicate the weaning from the ventilator and may
increase patient’s risk of complications.
Overuse of sedative medications increase
hospital costs not only by increasing the actual use
of medications, but by increasing the recovery time
of the patients and the length of stay as well.
Sedative medications and anesthetic agents
B e gi n n er ’s G ui de 73
have a direct effect on the brain, and therefore their
effects are best measured by EEG or evoked
potentials. Several analysis methods have been
developed for these signals, one of them is the
Bispectral IndexTM (BIS). It is a number which is
derived by analysing e.g. phase coupling of the
different frequencies of the EEG signal.
Picture 68. The BIS measurement.
Awake
BIS 100
Underdosing medication
Optimal depth of sedation and anesthesia
Overdosing medication
BIS 0
No brain activity
74 Be g i nne r ’s Gu i d e
The EEG for the BIS is obtained noninvasively
by a sensor placed on patient’s forehead (picture 68).
The numerical BIS value between 0-100 is displayed
on the monitor. It reflects the patient’s sedative/
hypnotic state. Zero means no brain activity and 100
means that the patient is fully awake (figure 1). For
general anesthesia BIS should be between 40 and
60.
BIS monitoring helps to safely reduce sedative
and anesthetic agent use to enhance patient’s
recovery and reduce hospital costs. BIS monitoring
assists in finding the optimal dosage of sedatives/
hypnotics to each patient. It also helps to predict
when a patient is waking up.
Figure 1. BIS monitoring assists in administering the
optimum amount of sedative and anesthetic agents.
TASKS 3.7 Monitoring Adequacy of Anesthesia
Q1 Which three things are monitored from inhalational anesthetic agents? ___________________________
____________________________, _______________________________, and _________________________
__________________________________________________________________________________________

Q2 What does one MAC mean? _________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

Q3 Why is agent identification important? ________________________________________________________

__________________________________________________________________________________________

Q4 What do neuromuscular blocking agents accomplish? ___________________________________________

__________________________________________________________________________________________

Q5 Train-of-Four Ratio is _______________________________________________________________________

Q6 How is the effect of neuromuscular blockers terminated? _______________________________________

__________________________________________________________________________________________

Q7 What is BIS used for? _______________________________________________________________________

__________________________________________________________________________________________

Q8 What is BIS calculated from? ________________________________________________________________

__________________________________________________________________________________________

Q9 What BIS value range assures that patient is sleeping during surgery? _____________________________
__________________________________________________________________________________________

B e gi n n er ’s G ui de 75
3.8 Monitoring Temperature
The balance between heat production and heat loss
determines the body temperature. Metabolic
processes and muscular activity (including
shivering) produce body heat. Heat is lost mainly by
radiation, conduction, convection and vaporization.
Normal Temperature Values
Temperature can be measured from different sites of
the body. Core temperature can be measured from
the blood by a pulmonary artery catheter, from the
rectum, esophagus, or armpit with a temperature
probe, from the bladder with a special urinary
catheter, or from the eardrum with a tympanic
thermometer. The measurement(s) should be taken
at appropriate sites where there is least risk to the
TASKS 3.8 Monitoring Temperature
Q1 Where in a body can temperature be monitored from? __________________________________________
__________________________________________________________________________________________
76 Be g i nne r ’s Gu i d e
patient and no obstacles to good thermal contact.
During long periods of monitoring and with
newborn babies, the possible redistribution of heat
can be detected by monitoring the differences
between temperatures of different sites. The
temperature of patient’s extremities reflects the
condition of the blood circulation. If the circulation
is compromised the temperature measured at
patient’s foot will fall below 32 centigrade.
Body temperature is normally maintained
within limits of ± 2°C, despite large variations in
ambient temperature. The temperature is different
at different sites in the body, being lowest on the
skin of the extremities and highest in the core of the
body. Normal values range from 32°C on the skin to
around 38°C in the core.
4 ANSWERS TO THE TASKS
TASKS 1.1 Emergency
A1 A sudden medical crisis, a life threatening A3 20 %
natural disaster, or a situation when a
person’s psychological or physiological A4 Unpredictable, challenging, hectic at times,
integrity is impaired rewarding

A2 Triage means quick assessment of the

urgency of patient’s problem, desicion for the
best place to treat it, and priorisation of
patient care

TASKS 1.2 Anesthesia

A1 A4 EtO2 and I-EO2

A5 A mixture of oxygen, nitrous oxide or air and

anesthetic agents

A6 To remove fear, to protect the patient from

analgesia, painlessness relaxation complications and to decrease secretions

A7 Halothane, enflurane, isoflurane, sevoflurane

and desflurane

unconsciousness A8 An anesthesia machine, usually including

ventilator
A2 Local, regional and general anesthesia
A9 A non-rebreathing system and a rebreathing
A3 Induction system

TASKS 1.3 Critical Care

A1 to maintain vital organ function and preserve A4 to support the vital organ function and to take
life while treating underlying disease care of sufficient oxygen delivery to the
tissues
A2 there must be enough space, good visibility,
possible need for isolation, patient’s privacy A5 enterally, parenterally

A3 they take care of patient’s respiratory A6 his condition is stable and the underlying
assessment, draw and interpret blood gases, disease is cured
check and adjust ventilators, give
physiotherapy and inhalable medications,
suction patients, and resuscitate patients

B e gi n n er ’s G ui de 77
TASKS 1.4 Transport
A1 Patient’s safety during the transport A3 Patient’s unpredictable reaction to transport,
shortage of equipment, machine failure, lack
A2 Prepared and adequate number of staff, of gases or electricity, traffic accident...
appropriate equipment and mode of
transportation, extensive monitoring, careful A4 with thorough preparation, and experienced,
stabilization of the patient prior to transport, prepared staff
full, continual assessment, care, and review of
the patient, accurate documentation, and
direct handover

TASKS 2.1 Breathing

A1 the nose, the throat, the windpipe, the A7 Perfusion means the blood flow through the
bronchi and the bronchioles capillary bed

A2 The epiglottis is a switch between the trachea A8 Diffusion is the spontaneous movement of
and the esophagus: an open epiglottis allows molecules from a region of higher
air to enter the lungs, a closed epiglottis leads concentration/partial pressure to a region of
food to esophagus lower concentration/partial pressure

A3 The air volume in the airways which does not A9 placing the tube into the esophagus,
participate in gas exchange advancing the tube into the right bronchus,
and obstructions in the tube
A4 the diaphram and the external intercostal
muscles A10 7 mg/l

A5 carbon dioxide A11 to remove CO2, to oxygenate the blood, to

humidify the airways, to support spontaneous
A6 Ventilation is movement of gases into and out breathing, and to decrease the work of
from the lungs breathing

TASKS 2.2 Heart and Blood Circulation

A1 to supply oxygen and nutrients to tissues, A3
return carbon dioxide to lungs, and other Superior
waste products to the liver and kidneys vena cava Aorta
Pulmonary
artery
A2 The systemic circulation transports the
oxygenated blood from the heart to the rest of Pulmonary
the organs and tissues, and returns back to valve
the heart. The pulmonary circulation LA Aortic
Inferior valve
transports deoxygenated blood from the heart vena cava RA
to the lungs to be oxygenated, and returns it
to the heart. The coronary circulation delivers LV
Mitral
oxygenated blood to the heart muscle itself. RV
valve
Tricuspid
valve

78 Be g i nne r ’s Gu i d e
A4 Electrocardiogram (ECG) records the changes A9 4,9 L/min
of the charge distribution occurring in cardiac
cells during heartbeat A10 preload, contractility and afterload

A5 myocardium A11 The dilation of capillaries happens only near

the open alveoli, so there is no shunting of the
A6 lack of oxygen in the heart muscle blood, and the oxygenation hopefully
improves. Inhaled NO effects only pulmonary
A7 lack of oxygen, electrolyte imbalance, or circulation, the systemic effect (possible drop
myocardial infarction in the blood pressure) is avoided.

A8 C.O. is the amount of blood heart ejects in

one minute; it indicates, how well the heart is
functioning

TASKS 2.3 Metabolism

A1 the process of converting nutrients and A5 Shivering, convulsions, injury, infection,
oxygen into energy and heat anxiety, fever, increased work of breathing

A2 CO2, the by-product of oxidation, is removed A6 Hypotermia, circulatory shock, deep sleep,
by breathing muscle relaxation

A3 The cell uses anaerobic metabolic processes A7 Carbohydrates and fat

which produce lactic acid, and cause acidosis
A8 RQ is the ratio between carbon dioxide
A4 250 ml/min, 200 ml/min production and oxygen consumption

TASKS 2.4 Nervous System

A1 to sense changes from inside and out of the
body, analyze the sensed information, make
decisions what to do about the sensed
changes, and give orders to the body how to
respond to the changes
A2 the brain and the spinal cord
A3 The sympathetic nervous system prepares the
body to “fight or flight”, speeding the heart
and blood circulation. The parasympathetic
nervous system promotes food digestion and
other relaxing actions.
A4 neurons
A5 sleep, many drugs, anesthetics, hypothermia,
chemical imbalance, and lack of oxygen
A6 increased body temperature
A7 It causes shivering which increases oxygen
consumption and CO2 production, effects the
blood circulation, and blood clotting system
A8 It impairs the normal temperature regulation
of the body, exposing it to hypothermia

B e gi n n er ’s G ui de 79
TASKS 3.1 Monitoring Ventilation
A1 It helps to optimize ventilation, and to prevent
and diagnose problems with the ventilator or
the endotracheal/tracheostomy tube
A2 numerically and graphically, integrated with
other parameters on the monitor
A3 I:E is the ratio between inspiratory and
expiratory times. Ppeak is the peak pressure,
the maximum pressure exerted at the patient
airway. PEEP is the positive end expiratory
pressure remaining in the lung at the end of
expiration. Compl is compliance, a measure
of the distensibility of the lung-thoracic
system. Raw is airway resistance
TASKS 3.2 Monitoring Oxygenation
A1 the amount of inhaled and exhaled oxygen
A2 Possible leaks in patient circuit and low fresh
gas flow affect the oxygen measurement done
in the ventilator. The measurement done at
the patient airway gives information about
the patient’s lungs and the function of the
breathing circuit.
A3 the oxygen saturation of arterial blood
A4 If the displayed saturation value is based on
true arterial blood flow or on artifact or
interference
TASKS 3.3 Monitoring Metabolism by Gas Exchange
A1 It means the measurement of how
much energy is used, by measuring
pulmonary gas exchange
A2 RQ approximates if patient is using
mainly carbohydrates, proteins or fat
for energy production
80 Be g i nne r ’s Gu i d e
A4 The resistance of ventilator tubing and the ET-
tube, and the surface tension of the alveoli
must be overcome by increasing the pressure
before the flow can start
A5 capnogram
A6 ventilation, circulation, and metabolism
A7 patient breathing against the ventilator,
obstruction in the airway or increased airway
resistance, and mechanical irritation of the
abdominal area by the operating surgeon
A5 If there is poor peripheral blood perfusion,
there is no signal, and if there is a lot of
COHb in the blood, the oxygen saturation is
over estimated
A6 the oxygen amount returning to the right side
of the heart
A7 the blood coming from different organs has
varying amount of oxygen in it, and the blood
returning to the heart is a mixture of all the
blood and varying oxygen saturations
A8 inspired oxygen amount, the oxygen amount
in arterial blood, the transporting capacity of
blood (presence of hemoglobin and good
cardiac output) and how much oxygen the
tissues have used
A3 to optimize patient’s nutrition, and to assess
his overall oxygenation status
TASKS 3.4 Monitoring Blood Circulation
A1 millimeters of mercury (mmHg) A7 C.I. is C.O. divided by the patient’s body
surface area, to proportion the C.O. to
A2 CVP, PAP, PCWP patient’s size

A3 mean arterial pressure A8 the volume and the temperature of the

injectate, and the temperature of the blood
A4 Central venous pressure (CVP) is measured at
the superior vena cava or the right atrium A9 the adequacy of the blood circulation in the
stomach and the gut
A5 Pulmonary capillary wedge pressure (PCWP)
gives information about the filling pressures A10 slightly higher
in the left side of the heart
A11 It gives diagnostic information which helps to
A6 C.O. = stroke volume x heart rate identify and intervene patient’s problems
early, before the problems are seen in other
parameters

TASKS 3.5 Monitoring Electrocardiography

A1 ECG measures the electrical impulses A3 that the segment between S- and T-waves is
conducted in the heart above the baseline, it may be caused by
ischemia of the heart muscle
A2 direction, strength, and duration of an
electrical impulse A4 Some arrhythmias are life threatening, and
some less dangerous ones may deteriorate to a
lethal level

TASKS 3.6 Monitoring EEG

A1 the spontaneous electrical activity of the A5 EEG may change due to changes in the level
surface layer of the brain of consciousness, oxygenation of the brain,
and patient temperature
A2 to evaluate the skin contact of the electrodes
A6 latency, amplitude, and existence and non-
A3 5 kilo-ohms existence of certain waves

A4 by prepping the skin well: removing grease

and dead cells from the skin surface

B e gi n n er ’s G ui de 81
TASKS 3.7 Monitoring Adequacy of Anesthesia
A1 Gas in use is identified, its concentration is A5 TOF% is the ratio of the fourth muscle
measured, and a MAC value is calculated response to the first one

A2 One MAC means how much of the A6 through metabolism or by giving an antidote
inhalational anesthetic agent is needed for 50
% of average 50 year old, 70 kg population not A7 BIS is used to determine the depth of patient’s
to react to skin incision anesthesia

A3 to notice misfilled or contaminated vaporizer, A8 It is calculated from the patient’s raw EEG
or identify the agent used, when there are two
anesthetic agents present A9 40-60

A4 They prevent the normal transmission of an

impulse from the nerve to the muscle

TASKS 3.8 Monitoring Temperature

A1 blood, rectum, esophagus, skin, and bladder

82 Be g i nne r ’s Gu i d e
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