MS-III Introductory Lectures in Anesthesiology

Basic Anesthesia Monitoring in the Operating Room

Department of Anesthesiology Uniformed Services University of the Health Sciences

American Society of Anesthesiology (ASA) Standards for Basic Intraoperative Monitoring

Department of Anesthesiology Uniformed Services University of the Health Sciences

ASA Standards
Applies to all anesthesia care except labor and pain

management Certain criteria may be waived in extenuating circumstances

should document circumstances in chart potential criteria highlighted in future slides

Definitions Continually - repeated regularly and frequently Continuous - without interruption

Department of Anesthesiology Uniformed Services University of the Health Sciences

Standard I
Qualified personnel shall be present in the operating

room throughout all:

General Anesthetics Regional Anesthetics Monitored Anesthesia Care

Temporary Absence Exceptions hazardous conditions for anesthesia provider

provide for remote monitoring

emergency situations

Department of Anesthesiology Uniformed Services University of the Health Sciences

Standard II
During all anesthetics the following

parameters will be continually monitored:

oxygenation ventilation circulation temperature

Department of Anesthesiology Uniformed Services University of the Health Sciences

Oxygenation
Objective

ensure adequate oxygen concentration in inspired gas and blood

Methods

inspired gas oxygen analyzer with alarms (GA) pulse oximetry illumination and exposure to assess color

Department of Anesthesiology Uniformed Services University of the Health Sciences

Pulse Oximetry
Theory two wavelengths (660 and 960 nm) calculates functional saturation (physiologic saturation) Limitations dyes or other hemoglobin species (carboxy, met, fetal, etc) motion low perfusion states electrocautery ambient light

Department of Anesthesiology Uniformed Services University of the Health Sciences

Pulse Oximetry
Optical plethysmography

detects pulsatile changes in blood volume measures pulsatile hemoglobin saturation all pulsation is arterial light passes through pulsatile beds
Department of Anesthesiology Uniformed Services University of the Health Sciences

Spectrophotometry

Assumptions

Ventilation
Objective ensure adequate ventilation of patient

Methods qualitative clinical signs

quantitative measurement

chest excursion observation of reservoir bag auscultation of breath sounds

end tidal carbon dioxide volume of expired gas continuous circuit disconnect monitor for mechanical ventilation

Department of Anesthesiology Uniformed Services University of the Health Sciences

Ventilation
General Anesthesia qualitative clinical signs adequate quantitative methods encouraged endotracheal tube or laryngeal mask placement

continual end tidal carbon dioxide identification

continuous disconnect alarm mandatory during controlled ventilation

Regional Anesthesia and Monitored Anesthesia Care continual qualitative clinical signs (minimum)

Department of Anesthesiology Uniformed Services University of the Health Sciences

Capnography
Theory main or sidestream sampling several technical methods available

IR, raman gas scattering, mass or photoacoustic spectroscopy

Applications confirmation of intubation monitoring for circuit disconnection identification of airway obstruction rebreathing/metabolic monitoring

Department of Anesthesiology Uniformed Services University of the Health Sciences

Circulation
Objective

ensure adequacy of circulatory function continuous electrocardiogram monitoring arterial blood pressure and heart rate q 5 min during GA one additional continual parameter
palpation of pulse doppler peripheral pulse auscultation of breath sounds pulse plethysmography intra-arterial pressure trace pulse oximetry
Department of Anesthesiology Uniformed Services University of the Health Sciences

Methods

Temperature
Objective aid in maintaining appropriate body temperature Application readily available method to continuously monitor temperature if changes are intended, anticipated or suspected Methods thermistor temperature sensitive chemical reactions location

Department of Anesthesiology Uniformed Services University of the Health Sciences

Intra-arterial Blood Pressure

Equipment

transducer and pressure monitor upper extremity lower extremity superficial temporal

Monitoring location

Technique

Department of Anesthesiology Uniformed Services University of the Health Sciences

Noninvasive Blood Pressure

Methodology

oscillometric algorithms automated reproducible

cuff size
oversize

Limitations

erroneously low measurements to small erroneously high

Department of Anesthesiology Uniformed Services University of the Health Sciences

Electrocardiogram
3 vs. 5 electrode system three versus seven leads for diagnostic purposes
Heart rate measurement R wave counting (any lead) Ischemia Monitoring lead II and V5 are 90% sensitive lead II, V5 and V4 up to 98% sensitive

Arrhythmia monitoring lead II or esophageal for supraventricular arrhythmias all leads for ventricular arrhythmias

Department of Anesthesiology Uniformed Services University of the Health Sciences

Neuromuscular Function
Evaluation of Reversal of Blockade
Clinical Criteria head lift > 5 seconds sustained hand grip negative inspiratory force

at least -55 cmH2O for adults at least -32 cmH2O for children

Evoked Response Criteria 1-2 twitches prior to reversal sustained tetanus to 50 Hz supra-maximal stimulus no fade on DBS

vital capacity 15 ml/kg absence of nystagmus or diplopia

Department of Anesthesiology Uniformed Services University of the Health Sciences

Neuromuscular Blockade
Site of Stimulation

ulnar vs. facial vs. posterior tibial supra-maximal, 0.2 msec, square wave

Characteristics of Electrical Stimuli

Patterns of Stimulation single twitch train of four double burst stimulation

sustained tetanus @ 50 Hz for 5 seconds post tetanic potentiation

Department of Anesthesiology Uniformed Services University of the Health Sciences