Presented by Dr.

Mustafa Ahmed Jerjess Senior lecturer/ Faculty of Medicine UiTM

 This is one of important subjects in anesthesia discipline and career because it makes the line of demarcation between a good and bad Anaesthesiologist. It represent the sum of duties of Anesthesiologist towards the patient.

 Q: What is Perioperative Anesthetic Care? A: Its the art of: 1. Maintaining safety and comfort of patient intra and postoperatively. 2. Avoiding any anticipated complication due to type of surgery and/or anesthesia or due to patient general health condition. 3. Treating any complication or critical event that may occur intra or postoperatively. 4. Providing the most favorable conditions for the success of operation.

 So from the definition the care takes place in intra and postoperative so why it is called perioperative care? The answer is simple and practical because the 1st step of care is started preoperatively by optimizing the patient condition and setting the anesthesia care plan.

 So what are the component of anaesthetic care? 1. Preoperative optimization of patient health condition. 2. Monitoring. 3. Administration anaesthesia drugs and procedures. 4. Protection of body against any internal or external risk. 5. Maintenance of body organs function in preoperative state or even improving them. 6. Maintenance of body essential requirements. 7. Replacement of any loss. 8. Treatment of any critical event.

 In this lecture we will concentrate on monitoring subject because the other subjects are covered by other lectures in surgery module. So lets go for monitoring.

 Monitoring is an essential issue in anaesthetic care helping anaesthesiologist to avoid and early detect any complication and critical event perioperatively. Appropriate monitoring should be available whenever and wherever anaesthesia is conducted, whether in anaesthetic room, operation theatre, psychiatry or X-ray department or in dental surgeries.

 Anaesthetic monitoring is 2 types : 1.Anaesthetic equipment monitoring: a.Clinical. b.Instrumental. 2.Patient monitoring. a.Clinical. b.Instrumental.

a. Clinical: this includes reviewing check list for the function integrity of all anaesthetic equipments (e.g. anaesthetic machine, ventilator, patient monitor, laryngoscope). This should be done before the start of induction. Clinical monitoring also include continuous correlating the function anaesthetic equipment to effects seen on the patient.

b. Instrumental: we have monitors or equipments that give us parameters of other equipment function e.g. percentage of inspired (O2, volatile anaesthetic, N2O, C O2 etc) ventilator monitoring screen and many other equipments.

a. Clinical: this is very important because we dont depend completely on the instrument on the contrary we always depend on our analysis of parameters shown by the monitor in addition to the continuous examination of patient by inspection, palpation, auscultation and to limited extent percussion.

b. Instrumental: today we have a lot of monitoring devices and every year a device is added to the set of monitors in anaesthesia. Because of complicated nature of some monitoring devices and invasiveness of others the use of monitoring devices is divided to 2 groups.

1.

1) 2) 3) 4) 5) 6)

Basic group: this includes an essential monitoring devices for the safe conduct of anesthesia that should available whenever and wherever anaesthesia is administrated. This includes: ECG monitor(with respiratory rate measurement). Pulse oximeter. Non-invasive blood pressure. Capnography. Inspired O2 concentration analyser. Temperature measurement.

Also we have additional devices in the basic group: 1) Ventilator monitor: (if ventilator is used). 2) Peripheral nerve stimulator: (if muscle relaxant is given). 3) Inspired anaesthetic vapour concentration analyser: (if available).

2. Specialized: these monitoring devices are use only when there is special surgery or patient condition. This includes: a. Invasive blood pressure. b. Urine output. c. Central venous pressure. d. Pulmonary artery pressure. e. Cardiac output.

Pulse oximeter: is a device used to measure the percentage of hemoglobin (Hb) that is saturated with oxygen. This oxygen saturation (SpO2) is a measure of how much oxygen the blood is carrying. It also measure the pulse rate and waveform. The later give us an idea about the character of the pulse.

The contraction and relaxation of cardiac muscle results from the depolarisation and repolarisation of myocardial cells. These electrical changes are recorded via electrodes placed on the limbs and chest wall and displayed as a wave on the monitor screen. Usually the monitor display one lead only but in some advanced monitors they can display all 12 leads ECG. In addition to displaying any arrhythmias it can also be used to detect the possibility of myocardial ischemia, electrolyte imbalances, assess pacemaker function and calculate heart rate . But not the cardiac out put or myocardial function.

The capnogram is a direct monitor of the inhaled and exhaled concentration or partial pressure of CO2, and an indirect monitor of the CO2 partial pressure in the arterial blood. Capnography provides a rapid and reliable method to detect life-threatening conditions (malposition of tracheal tubes, unsuspected ventilatory failure, circulatory failure and defective breathing circuits) and to circumvent potentially irreversible patient injury. Capnography and pulse oximeter together could have helped in the prevention of 93% of avoidable anesthesia mishaps according to (American Society of Anesthesiologists) closed claim study.

This is the most common method of obtaining the patients blood pressure during anesthesia and surgery. A pneumatic cuff with a width that is 40% of the arm circumference must be used and the internal inatable bladder should encircle at least half the arm. An electrical pump inates the cuff, which then undergoes controlled deation. A microprocessorcontrolled pressure transducer detects variations in cuff pressure resulting from transmitted arterial pulsations. Initial pulsations represent systolic blood pressure and peak amplitude of the pulsations equates to mean arterial pressure. Diastolic is calculated using an algorithm.

 Continuous monitoring of the oxygen concentration in the inspired gas mixture is considered essential. This is usually achieved using an oxygen analyser that displays a numeric value of oxygen concentration. Its essential because it prevents the administration of hypoxic gas mixture (low O2 concentration) to patient which caused a lot of tragic accidents during anaesthesia in the past.

This is became one of the essential monitors because of the progressive evolution of anesthetic ventilators with more complexity sophistication of functions.

After the spread of closed circuit anesthesia (a modality that reduces the amount of volatile anesthetic usage) with invention of multiple volatile anesthetic agents it was mandatory to monitor the inspired concentration of these agents.

 Note: Now it no longer we use multiple devices for monitoring of multiple parameters, instead of that we use a single monitor to monitor all parameters we want.

 Usually the recovery which is a part of intraoperative care takes place in recovery room and takes short time (most of the time less than 1 hour), but in special cases(e.g. neurosurgical patient) where the recovery may take more than usual or the patient condition is critical then we refer the patient to Intensive care unit where full monitoring facility is available just like intraoperative monitoring in addition to full analgesia and other maintenance therapy. Otherwise if the patient condition is satisfactory then we send the patient to general ward with full prescription of postoperative analgesia and fluid therapy.