DIVISION OF SURGERY

ASSIGNMENT ON
MONITORING OF POST SURGICAL PATIENT
OR TRAUMATISED PATIENT
SUBMITTED TO: DR ABHISHEK SAXENA
(SCIENTIST)
PRESENTED BY :
DR ABAS RASHID
BHAT (MVSC SCHOLAR)
M-5324

What is Patient Monitoring?

Repeated or continuous observations or measurements of the
patient, its physiological function, and the function of life
support equipment, for the purpose of guiding management
decisions, including when to make therapeutic interventions, and
assessment of those interventions
A patient monitor may not only alert caregivers to potentially
life-threatening events; many provide physiologic input data used
to control directly connected life-support devices.

INTRODUCTION
Monitoring of traumatised or post surgical patient is
almost same.
Postoperative care begins in the recovery room or
when the traumatised patient is presented to you.
Continues throughout the recovery period .

Dr. Rebecca Kirby, one of the founding

Diplomates of the American College of Veterinary
Emergency and Critical Care, developed a list of 20
important things to monitor in any critically
ill patient on a daily basis.

KIRBYS RULE OF TWENTY

1. Fluid balance
2. Blood pressure and perfusion
3. Cardiac function (rhythm, rate and contractility)
4. Albumin
5. Oncotic pull
6. Oxygenation/ventilation
7. Glucose
8. Electrolyte and acid-base balance
9. Mentation/intracranial pressure
10. Coagulation
11. RBC/hemoglobin concentration
12. Renal function and urine output
13. Immune status, WBC, and antibiotic coverage
14. GI motility and integrity
15. Drug metabolism and drug doses
16. Nutrition
17. Analgesia
18. Nursing care, patient mobility
19. Bandage and wound care
20. Tender loving care

1) GENERAL CONDITION
The

overall appearance of a patient is non-specific

parameter for health.
It includes1. Alertness
2. Muscle tone
3. posture
4. Appetite
5. Pattern of breathing

.FLUID BALANCE
Foremost
Pulse quality ,CRT and Heart rate are
measured(perfusion parameters).

In a dog, a shock volume of fluid is 90 ml/kg. (In a

cat, the recommended shock volume is of this, at
45 ml/kg).

Give 1/4 of crystalloid shock volume as bolus

Thumb rule is body wt. in pounds,add zero as suffix
Reasses the perfusion parameters

If not working repeat or give colloids like

pentastarch@5ml/kg iv bolus

CAPILLARY REFILL TIME CRT is a simple method to assess tissue perfusion.

If area of membrane is blenched with pressure of a
finger tip on release of that pressure blood flow
and hence return of color are slower than normal.
The capillary refill time (CRT) is a common indication
of dehydration and decreased peripheral perfusion
Normal CRT may be shown by low pressure with
vasodilation as in deep anesthesia
Prolonged CRT apprehensive patient, peripheral
vasoconstriction with normal BP.

MONITORINGFor dogs and cats CRT=1.5S

CRT

can be assess using accessible

nonpigmented oral mucus
membrane
Digital pressure is applied for a
short time (1 or 2 sec) & rapidly
released . The time needed for the
blanched area to return the color of
surounding membrane is CRT
CRT is generally judged as normal
or abnormal by simple observation.

CARDIOVASCULSAR MONITORING

BP: Function of cardiac

output and systemic
vascular resistance.

ECG is used to asses the

cardiac function.

For every affection ... that

is attended with either pain
or pleasure, hope or fear, is
the cause of an agitation
whose influence extends to
the heart.

The ECG provides

useful information
about ischaemia,
arrhythmias,
electrolyte
imbalance and drug
toxicity.

LEAD PLACEMENT

ECG warns about

Tachychardia,arrhythemias,atrail
flutter,ventricular
tachyarrhythemias,SVT,bradycardias

Reasons are anaesthetic drugs,trauma and

surgical interventions.

CLOSE monotoring of ECG will warn of any

dysrryhthymias and need of pharmological
intervention.
Managed by antiarrhythmic drugs.

CARDIAC OUTPUT
CO is the volume of blood pumped per unit time & is
product of heart rate and stroke volume
It

is influenced by venous return, peripheral resistence,

blood volume, heart rate, stroke volume, & cardiac
contractility.

After

moderate to major surgical operation resting CO

may be increased by 5-30%
Cardiac output/patient s body surface area in m2
provides the cardiac index

MONITORING CO can be calculated by using O2 consumption

measurement or measured using the indicator
dilution method
Most

commonly used clinical method is use of

balloon tipped catheters with thermistors at
their distal ends along with minicomputers
This method is rapid, reliable, easy, safe, & repeatable
Can be used in small patient.
It does not require removal of blood

CVP
Central venous pressure (CVP) is the luminal
pressure of the intra thoracic vena cava.
Peripheral venous pressure is variably higher
than CVP,
subject to unpredictable extraneous influences
not a reliable indicator of CVP.
Placement of central venous catheters is
contraindicated in patients with known
coagulopathies.

CVP is the most common

parameter used to guide fluid
therapy in a patient with
hypovolaemia following
trauma, shock, burns, or
sepsis

CVP CATHETERS ARE placed

in the jugular vein connected to
manometer.

The normal C V P in small animals is 0 to 5cm H 2 0 .

Values
< 0 is absolute or relative hypovolemia
5 10 is borderline hypovolemia.
>10 is volume overload.
>15 may be CHF and development of pulmonary
oedema
It is 15 to 30 cm H 2 0 in laterally recumbent horses,
and 5 to 10 cm H 2 0 in dorsally recumbent horses.

Aretrial Blood Pressure

Arterial blood pressure is a consequence of the

relationship between blood volume and blood
volume capacity

Arterial blood pressure is a primary determinant of

cerebral and coronary perfusiON.

Systolic blood pressure is

primarily determined by
stroke volume and arterial
compliance.
Diastolic blood pressure is
primarily determined by
systemic vascular
resistance and heart rate.
Mean blood pressure is the
average pressure one-half
of the area of the pulsepressure waveform
MAP=2/3DP=1/3SP

Mean arterial pressure is required for the

calculation of systemic vascular resistance .

Often given automatically by many of the electrical

monitors of blood pressure and cardiac output.

Normal Arterial Blood Pressures

Dogs Systolic 140, Mean 100, Diastolic 75 mm Hg

Cats - Systolic 180, Mean 135, Diastolic 100 mm Hg
Horses - Systolic 110, Mean 90, Diastolic 70 mm Hg

Pulmonary Monitoring
Breathing Rate
Breathing Rhythm
Nature and Effort

MONITORING

Assessing & monitoring ventilatory efficiency is

done by thaughtful observation, stethescopy,
ventilometery, and when indicated, radiography.
Tidal volume can be estimated by Observing chest
Placing ear near nostrils or mouth to feel and hear the
puff of air expired
Holding a polished metal surface infront of the nostrils
Ventilometer attached by a short ridged tube to a tight
fitting face mask or fitted tracheal tube.

ABG ANALYSIS

Pa CO2
P a C 0 2 is a measure of the ventilatory status of a
patient and normally ranges between 35 and 45 mm Hg

Pa O2
Pa02 measures the tension of oxygen dissolved in the
plasma, irrespective of the hemoglobin concentration.

SO2 (Saturation of oxygen in Haemoglbin)

SATURATION OF O2 IN Hb(pulse oximetery)

A NON INVASIVE TECHNOLGY TO MONITOR OXYGEN
SATURATION OF THE HAEMOGLOBIN

PRINCIPLE
ABSORBTION SPECTRO PHOTOMETRY
BEER LAMBERT LAW

Substances have a specific pattern of absorbing specific

wavelength Extinction coefficient
Uses two lights of wavelengths

660nm deoxy Hb absorbs ten times as oxy hb

940 nm absorption of oxyHb is greater

oxyHb absorbs infrared.

deoxyhb absorbs red.

Sao2
SaO2

(functioal saturation) = HbO2/HbO2+Hb

Fractional

saturation =

HbO2
-------------------------HbO2+ Hb+ Met Hb +CO Hb

Saturation is defined as ratio of O2 content to oxygen capacity of Hb

expressed as a percentage.

Desaturation leads to Hypoxemia a relative deficiency of O2 in

arterial blood. PaO2 < 80mmHg hypoxemia.

Oxygen saturation will not decrease until PaO2 is below 85mmHg.

At SaO2 of 90% PaO2 is already 60mmHg.

SaO2< than 76% is life threatening.

PaO2 [mmHg]

SaO2 [%]

Normal

97 to 80

Hypoxia < 80

Mild

Moderate 40 59

75 89

Severe

< 75

60-79

<40

97 to 95
<95

90-94

O2 THERAPY
Oxygen flow rates of 50 150
ml/kg/min of humidified oxygen
should be provided until the
patient can tolerate room air (21%
FiO2) without signs of respiratory
distress.

pH

TISSUE pH

of interstitial fluid is normally very near that of

blood
Poor tissue perfusion tissue pH < arterial blood
pH
This is b/c of accumulation of lactic acid into tissue
space due to anerobic metabolism
This change closly follows changes in local blood
flow
So tissue pH is used to assess tissue perfusion

MONITORING This is monitored using a special pH electrode &

a pH meter.
Electrode is placed on the surface of a
superficial muscle after giving a cut & secured
by a bandage.
This method is simple & needs only reletivly inexpensive
equipment
Needle electrods are also available

Renal Monitoring

Urine Flow indirect measure of Renal Blood Flow

Bladder catheterisation is done for monotoring

Normal urine output should be about 1 to 2 mL/kg/h.

Oliguria or anuria, per se, can be treated,after

ensuring that renal perfusion is adequate, with
furosemide (0.5- to 5-mg/kg bolus 0 . 1 to 0.5
mg/kg/h) or mannitol (0.5- g/kg bolus 0.1 g/kg/h)

: Albumin and Colloid Oncotic

Pressure
During

acute blood loss, there is also a loss of

serum protein.

LEVEL

OF ALBUMIN should be monitored.

Administration

of a colloid such as hydroxyethyl

starch (20 -30 ml/kg/day IV CRI) or pentastarch
(20 30 ml/kg/day IV CRI) can be beneficial

GLUCOSE
Traumatised patients are usually hyperglycemic.
SERUM GLUCOSE levels are monitored after
every 1-2 hrs.

Drugs promoting hyperglycemia are cotraindicated

in head trauma.
Do not use corticosteriods.
Electrolyte and acid-base balance
traumatized patients are at risk for metabolic
or lactic acidosis.In ruptured urinary bladder,
the patient is at risk of hyperkalemia.

Anionic gap should be monitored for accurate fluid

therapy.
Electrolyte imbalances are reflected by ECG.
Hypokalemia
Hyperkalemia
Hypercalcemia
Hypocalcemia

MONITORING Can be measured by blood pH & CO2 tension with a

blood gas analyzer.

Titration of anerobically obtained blood sample with acid

to determine bicarbonate content

. RBC/hemoglobin concentration:

Hemorhages due to trauma and surgery decrease Hb.

If PCV is reduced by half , the patients cardiac output must

double to meet the baseline requirement & must triple to
meet max. postoperative demand.

In critically ill patient , a PCV in the range of 27-33%

(corresponding Hb conc. 10-12) has been found to
be most compatible with survival.
BLOOD AND Hb levels are monitored.

Managed by crystalloids and blood transfusion.

ANALGESIA
Analgesia is paramount to patient well-being and
healing .
Monitored for its effects on physiological
responses.

Judicious use of opioid drugs, including patients

with head trauma, should be implemented to treat
pain and the negative consequences of pain.

Temperature
Hypothermia
Hyperthermia
MONITORED at regular intervals and managed
accordingly.

1.
2.
3.
4.
.

Warm thermoregulatory effector mechenism

includeVasodilation
Sweating
Panting
Salivation
Changes in the temp.may be due to

Anesthesia
Drugs
Tissue injury
Enviornmental exposure
Infection

BANDAGE AND WOUND CARE

Wounds Should Be Assessed On A Daily Basis, At
Minimum.
Bandages That Become Soiled Or Wet Should Be
Changed Immediately,
To Prevent Wicking Of Bacteria From The
Environment Into The Wound And Causing A
Nosocomial Infection.
Open wounds should be covered immediately at the
time of presentation.

NUTRITION
Enterocytes will undergo atrophy within 24 hours
of lack of enteral nutrition
Maintain positive N2 balance for quick healing.
ENTERAL FEEDING SHOULD BE DONE

Tender loving care

The last, but not least, aspect of Kirbys Rule of
Twenty is Tender Loving Care.
Allow the patients family to visit, whenever
possible.
Spend time with the patient soothing them, not
just during treatment times.

Questions ,discussion !

THANK YOU