Intra Anesthesia

Monitoring
Intraanesthesia monitoring
25 years ago was continuous palpation of
the radial pulsations
What is the value?

To understand of clinical monitoring.

RULE : clinical assessment is
much BETTER & much more
VALUABLE than the digital monitor.
Modern monitors have made life
much easier for us.
Intra anesthesia monitoring
Why do we need monitoring???
To maintain the normal pt physiology &
homeostasis throughout anesthesia and surgery
To ensure the well being of the pt.

Surgery is a very stressful condition.

Most drugs used for general & regional

anesthesia cause hemodynamic instability,
myocardial depression, hypotension &
arrhythmias.
Under GA the pt may be hypo or
hyperventilated and may develop
hypothermia.
Blood loss anemia, hypotension.
Intraoperative monitoring
The FOUR BASIC Monitors:
We are NOT start a surgery in the absence of
any of these monitors:
ECG.
SpO2: arterial O2 saturation.
Blood Pressure: NIBP (non-invasive), IBP (invasive).
[Capnography].
The most critical 2 times during anesthesia
are: INDUCTION - RECOVERY.
Exactly like flying a plane induction (=
take off) & recovery (= landing). smooth
induction & a smooth recovery & a smooth
intraoperative
(1) ECG
Monitoring: (1) ECG
Value:
Heart rate.

Rhythm (arrhythmias) best identified from lead II.

Ischemic changes & ST segment analysis.

Timing of ECG monitoring: Throughout the surgery:

before induction until after extubation & recovery.
Types & connections of ECG cables:
3-leads: Red=Right YeLLow=Left
Black=Apex (can read leads: I, II, III)
5-leads: Red=Right YeLLow=Left
Black=under red Green=under yellow
White=central (can read any of the 12
leads: I, II, III, avR, avL, avF, V1-V6).
Monitoring: (1) ECG
RULES:
QRS beep ON at all times. NO silent
monitors.
clinical assestment is much more
superior to the monitor. Check
peripheral pulsations.
Artefacts in ECG (noise/ electrical
interference) check radial
(peripheral) pulsations.
Arrythmias check radial
(peripheral) pulsations.
 ECG, EKG,
Electrocardiogram

The ECG is easy to understand

The abnormalities happen for a

reason
The electricity of the
heart
 What to expect ECG

Essential monitor

Rate, rhythm, ischemia

NO information about pump

function
3-lead system
Lead Selection
Lead II is the same as
standard lead two as
seen in a 12 lead
ECG.
The shape of the ECG

P T

Q
R
S
Normal ECG
 ECG interpretation
1. Rate

2. Rhythm

3. Intervals

4. QRS complexes

5. ST segments & T waves

Normal
Abnorma
l
 ECG abnormalities

Myocardial ischemia / infarction

Arrhythmias
 Myocardial ischemia /
infarction
ST depression

(0.1mv)

ST elevation

(0.2mv)

T wave inversion
Myocardial ischemia /
infarction
Bradyarrhythmias
Bradyarrhythmias
Bradyarrhythmias
Bradyarrhythmias : 2nd
degree AVB
Bradyarrhythmias : 2nd
degree AVB
Bradyarrhythmias : 3rd
degree AVB
 Tachyarrhythmias :
Premature complexes
 Tachyarrhythmias :
Premature complexes
Tachyarrhythmias
Tachyarrhythmias
Tachyarrhythmias
Tachyarrhythmias
Tachyarrhythmias
Asystole
(2) SpO2
Monitoring: (2) SpO2

It gives a LOT of information about the pt.

Definition: % of oxy-Hb / oxy + deoxy-Hb.
Timing of SpO2 monitoring: throughout
the surgery: before induction till after
extubation & recovery.
SpO2 monitoring should be continued in
recovery room.
monitoring: (2) SpO2

Value:
SpO2: arterial O2 saturation (oxygenation of
the pt).
HR.
Peripheral perfusion status (loss of
waveform in hypoperfusion states: hypotension
& cold extremeties).
Cardiac status.
monitoring: (2) SpO2
Readings:
Normal person on room air (O2 =

21%) 96%.
Patient under GA (100% O2) = 98-

100%.
It is not accepted below 96% with

100% O2 under GA.

< 90% = hypoxemia.

< 85% = severe hypoxemia.

Intraoperative monitoring: (2)
SpO2
Fallse:

Misplaced on the pts finger

Pt movement, shivering.
Poor tissue perfusion (cold extremities)
warm the pt, put a glove filled with
warm water in the pts hand (always
avoid hypothermia).
Poor tissue perfusion (hypotension &
shock).
Cardiac arrest.
(3) Blood Pressure
monitoring: (3) BP
NIBP: (non-invasive ABP monitoring = automated).
Gives readings for: systolic BP, diastolic BP & MAP:
Systolic/ diastolic (mean).
Value: to avoid and manage extremes of
hypotension & HTN. Systolic BP-Diastolic BP-
MAP.
Avoid MAP < 60 mmHg (for cerebral & renal
perfusion) & avoid diastolic pressure < 50
mmHg (for coronary perfusion).
Risks of HTN episodes: (CVS): myocardial
ischemia, pulmonary edema, (CNS): hemorrhagic
stoke, hypertensive encephalopathy. While
hypotensive episodes: (CVS): myocardial ischemia,
(CNS): ischemic stroke, hypoperfusion state
metabolic acidosis, delayed recovery, renal
shutdown.
monitoring: (3) BP
Timing of BP monitoring: throughout
the surgery: before induction till after
extubation & recovery.
Frequency of measurement:
By default every 5 minutes.
Every 3 minutes: immediately after spinal
anesthesia, in conditions of hemodynamic
instability, during hypotensive anesthesia.
Every 10 minutes: eg. In awake pts under
local anesthesia: monitored anesthesia
care (minimal hemodynamic changes).
 AVOID attaching it to an arm with A-V graft (for
renal dialysis) damage of AV graft, & inaccurate
measurements.
monitoring: (3) BP
Reading Error :
Pressure line is disconnected.

Leakage from damaged cuff.

Line is compressed (under someone)

Line contains water from washing!

Monitor error: cuff cannot inflate

 monitoring: (3) BP
IBP: (invasive arterial blood pressure monitoring)
It is beat to beat monitoring of ABP via an arterial

cannula.
Indicated in: major surgeries, during deliberate

hypotensive anesthesia, during the use of

inotropes, cardiac surgery, in surgeries involving
extreme hemodynamic changes/instability
(4) Capnography (CO2)
monitoring: (4) CO2
Definition:
What is Capnography?
Continuous CO2 measurement
displayed as a waveform sampled
from the patients airway during
ventilation.
What is EtCO2?
A point on the capnogram. It is the
final measurement at the endpoint of
the pts expiration before inspiration
begins again.
Intraoperative monitoring: (4) CO2
Normal range: 30-35 mmHg. (Usually
lower than arterial PaCO2 by 5-6 mmHg
due to dilution by dead space ventilation).
Value (data gained from capnography &
ETCO2):
ETT: esophageal intubation.
Ventilation: hypo & hyperventilation, curare
cleft (spontaneous breathing trials).
Pulmonary perfusion : pulmonary embolism.

Breathing circuit: disconnection, kink,

leakage, obstruction, unidirectional valve
dysfunction, rebreathing,
Cardiac arrest: adequacy of resuscitation
during cardiac arrest, and prognostic value
(outcome after cardiac arrest).
monitoring: (4) CO2
Factors affecting EtCO2: what what
EtCO2?
 Individual System
Monitoring
Position of ETT.
Respiratory System.
CVS & Hemodynamic Monitoring.
CNS: Awareness.
Temperature.
Monitoring after Extubation &
Recovery.
(A) Correct Position of ETT
(B) Respiratory Monitoring
Clinical monitoring:
Colour: cyanosis: nails, lips, palms,
conjunctiva.
Chest rise & fall (inflation).
Vapour in ETT (absent in ventilators with
humdifiers/if filter is used).
Airway pressure.
Ventilator bellows (return to full inflation
during expiratory phase).
Ventilator sound: during resp cycle.
Abnormal sounds eg. leakage,
disconnection, high airway pressure,
alarms.
(B) Respiratory Monitoring
N.B. Various alarms by the ventilator:
NEVER ignore an alarm by the ventilator!
Low airway pressure: leakage,
disconnection.
High airway pressure: kink, biting of the
tube, bronchospasm, slipped
esophagus.
Low expired tidal volume: leakage.
Apnea alarm: disconnection.
O2 sensor failure: (unfortunately common
in many of our ventilators).
Flow sensor failure: (unfortunately
common in many of our ventilators).
(B) Respiratory Monitoring
Respiratory Monitors:
O2 Saturation.
Capnography EtCO2.
Airway pressure.
ABG samples.
(C) CVS Hemodynamic Monitoring

Clinical monitoring:
Colour: pallor (lips, tongue, nails) = anemia,
shock.
Palpate peripheral pulsations every 10
minutes (Radial A, Dorsalis pedis A, Superficial
temporal A).
Capillary refilling time: compress nail bed
until it is blanched. After release of pressure
refilling should occur within 2 seconds. If 5
seconds = poor peripheral perfusion/circulation.
(C) CVS Hemodynamic Monitoring
Management of oliguria or anuria:
Check that the line is not kinked or

disconnected.
Palpate the urinary bladder (suprapubic

fullness), or ask the surgeon to palpate it.

Raise BP (MAP 80 mmHg): renal perfusion.

IV fluid challenge.

Diuretics.

N.B. Sometimes trendlenberg position (head

down) causes UOP. Reversal of this

position results in immediate flow of urine.
(C) CVS Hemodynamic Monitoring

CVS Monitors:
ECG.
Blood pressure (NIBP, IBP).
Central Venous Pressure: value:
indicator of:
1) IV volume.
2) RV function.
(E) Temperature Monitoring
Clinical monitoring: ur hands.
Monitors: temperature probe:
nasopharyngeal, esophageal.
AVOID hypothermia < 36oC. Why? &
How?
Especially in pediatrics & geriatrics
(extremes of age).
Why is it necessary to avoid
hypothermia? (complications of
hypothermia):
Cardiac arrhythmias: VT & cardiac arrest.
Myocardial depression.
Coagulopathy.
ect
(E) Temperature Monitoring
How to avoid hypothermia:
Warm IV fluids.
Intermittently switching off air-
conditioning esp. towards the
end of surgery.
Pediatrics: warming blanket.
(F) Monitoring After Extubation &
Recovery
After extubation
Good regular breathing with adequate tidal volume
transmitted to the bag.
No transmission to the bag respiratory obstruction
(
BP: within 20% of baseline.
SpO2: 92%
Breathing: regular, adequate tidal volume.
Muscle power: sustained head elevation for 5
seconds, good hand grip, tongue protrusion.
Level of consciousness: fully conscious = 1)
obeying orders, 2) eye opening, 3) purposeful
movement.
To Summarize:
How do I monitor the patient in OR?
The 4 basic monitors displayed on the
screen:
1) ECG.

2) BP.

3) SpO2.

4) Capnogram (EtCO2).
Normal target values for an adult
under GA:
HR: 60-90 ( 90 = tachycardia. <
60 = bradycardia).
BP: 90/60 140/90. MAP 60
mmHg (cerebral & renal
autoregulation). Diastolic BP 50
mmHg (coronary perfusion
pressure).
SpO2 96% on 100% O2.
EtCO2 = 30-35 mmHg.
 LISTEN
Listen to the monitor the whole
time:
To the pulse oximeter tone to identify: 1-
Heart rate 2- O2 saturation from the
tone (pitch) of pulse oximeter.
To the sound of the ventilator, to any
abnormal sounds, any alarms.
RULE: NO silent monitors. ALWAYS
keep the HR sound on. If ur monitor is
silent (sound is not working) u have to
look at your monitor the WHOLE time.
 LK
Every 5 minutes to note the new
BP reading.
If there is any change in the tone
of the pulse oximeter.
If there is any irregularity in
heart rate & during the use of
diathermy.
 Clinical Check / 10
1) Chest inflation.
minutes
2) Ventilator bellows: descend and return to
become fully inflated.
3) Airway pressure.
4) Palpate peripheral pulsations (radial A, or
dorsalis pedis A, or superficial temporal A):
For pulse volume.
During the use of cautery.
In doubt of ECG rhythm (arrythmias).
In case monitor or ECG disconnected.
5) Pt colour (nails): cyanosis, pallor.
6) Vaporizer:
a) Check concentration opened.
b) Level of the volatile agent (if needs to be filled).