![The FOUR basic monitors.
We are not authorizedto starta surgeryinthe absence ofany
ofthesemonitors:
ECG.
SpO2: arterial O2 saturation.
Blood Pressure: NIBP (non-invasive), IBP (invasive).
± [Capnography].
The mostcritical 2 timesduringanesthesiaare:
INDUCTION - RECOVERY.
Exactly like “flying aplane ” induction(= take off) &recovery
(= landing). The aimis to achieve a smooth induction&a
smooth recovery &a smooth intraoperative course.](https://image.slidesharecdn.com/iom2-230728162528-24002ae1/85/IntraOperative-Monitoring-8-320.jpg)
IntraOperative Monitoring
- 2. Introduction Monitoring of patients during surgical procedure.
- 3. A patient undergoing surgery under anesthesia is usually experiencing a number of disturbances with regard to the normal functioning of several body systems. This means that the patient’s physiological status needs to be monitored at all times Various sensors and electrodes are attached to the patient to gather information. These measurements are displayed on monitors.
- 4. Routinely measured parameters The parameters measured in most surgical procedures include: The heart’s electrical activity via an electrocardiogram The respiratory rate The blood pressure, which can be measured by both invasive and non-invasive means The body temperature via thermometers, especially when general anesthesia lasts over 30 minutes in duration. The cardiac output
- 5. The arterial blood oxygen level measured by a pulse oximeter, a photoelectric sensor clipped over the finger or toe. Pulmonary functions such as end-tidal carbon dioxide (ETCO2). Intracranial pressure monitor in patients suffering from trauma to the head, or brain tumors, edema, or intracranial hemorrhage. The sensor is inserted through a burr hole made in the skull.
- 6. History The mostprimitivemethodofmonitoringthe patient25 years agowas continuouspalpation of the radial pulsations through outthe operation.
- 7. Purpose To maintainthenormalpatientphysiology & homeostasis throughoutanesthesia andsurgery. Surgery is a very stressful conditiontachycardia, arrhythmias. Mostdrugsused for eneral ®ionalanesthesia cause cardiogenicshock, myocardialdepression, hypotension & arrhythmias. Blood loss →anemia, hypotension. So itis necessary to recognizewhenthepatientis inneed of blood transfusion.
- 8. The FOUR basic monitors. We are not authorizedto starta surgeryinthe absence ofany ofthesemonitors: ECG. SpO2: arterial O2 saturation. Blood Pressure: NIBP (non-invasive), IBP (invasive). ± [Capnography]. The mostcritical 2 timesduringanesthesiaare: INDUCTION - RECOVERY. Exactly like “flying aplane ” induction(= take off) &recovery (= landing). The aimis to achieve a smooth induction&a smooth recovery &a smooth intraoperative course.
- 9. (1) ECG Graphical representation of electrical activity of heart. The machine which is used to record the electrical activity of heart is ELECTROCARDIOGRAPH. The graph on which the electrical activity is recorded is called ELECTROCARDIOGRAM.
- 10. Significance of ECG ECG gives information about rate and rhythm of the heart. It is a diagnostic tool for various heart conditions like hypertrophies , ischemia, infarction , arrhythmias and pace maker activity. Timing ofECG monitoring:Throughout the surgery: before induction until recovery
- 11. ECG Paper • This is long role of paper ,composed of small squares. • One square is 1mmwideand 1 mm high. • On ECG paper there are thick lines, between two thick lines there are 5 small squares. • The speed of ECG machine is 25 mm per second.
- 12. • The time internal of each small square can be calculated as • 25 small sqrs are equal to 1 second. • 1 small sqr is equal to 1/25 second. • i.e 0.04 seconds.
- 13.
- 14. • vertically the small square represent the amount of electrical potential. • One small sqr represent the potential of 0.1 mv. • 10 small squares represent the potential of 1 mv.
- 15. ECG Leads There are 10 electrodes in 12 lead ECG placed on patients limbs and on the surface of chest.
- 16. How to attach ECG electrodes: Prepare the skin Before placing your electrodes, it is very important to prepare the subject's skin by wiping the chest area thoroughly with skin cleansing (alcohol) swabs. This removes any oil that may be on the skin and which can cause drift in your ECG/EKG signals. Once the skin is clean, find and mark the placements for the electrodes...
- 17. Find and mark the placements for the electrodes:
- 18. Apply limb leads
- 19. Wave Forms P wave Atrial depolarization QRS complex Ventricular depolarization T wave Ventricular repolarization
- 20. P Wave • P Waveshows atrial depolarization.. • Its duration is 0.1 sec (2 and half small sqr) and height is 2.5 mv (2 and half small sqr). • Presence of p waves in ECG strip shows the sinus rhythm.
- 21. QRS Complex QRS complex represent the ventricular depolarization. its normal duration is about 0. 08 seconds (less than 2 small sqr) and hight is about 5 to 20 small sqrs. Q wave is first wave of this complex but often absent.
- 22. Q wave present the interventricular depolarization. It is first wave in ECG with negative deflection. Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec are abnormal and may represent the old infarction.
- 23. T Wave • it represent the ventricular repolarization. • It is repolarizing wave but shows the upward deflection.
- 24. • T wave should not be more than one third of R wave. • T wave inversion represent ischemia of heart. • Tall and peaked R wave is present in hyperkalemia.
- 25. (2) SpO2 SpO2, also known as blood oxygen saturation, is a measure of the amount of oxygen-carrying hemoglobin in the blood. The body needs there to be a certain level of oxygen in the blood or it will not function as efficiently. In fact, very low levels of SpO2 can result in very serious symptoms. This condition is known as hypoxemia. There is a visible effect on the skin, known as cyanosis due to the blue (cyan) tint it takes on. Hypoxemia (low levels of oxygen in the blood) can turn into hypoxia (low levels of oxygen in the tissue).
- 26. Timing ofSpO2 monitoring: Throughoutthe surgery: It is the LAST monitortobe removed offthe ptbeforetheptis transferredoutside the operatingroomtorecovery room.SpO2 monitoringshouldbe continuedinrecovery room.
- 27. Measuring SpO2 • There are many ways that the blood can be tested to ensure it contains normal oxygen levels. The most common way is to use a pulse oximeter to measure the SpO2 levels in the blood. Pulse oximeters are relatively easy to use, and are common in health care facilities and at home.To use a pulse oximeter, simply place it on your finger. Can also be applied to the ear lobe. • A percentage will be displayed on the screen. This percentage should be between 94 percent and 100 percent, which indicates a healthy level of hemoglobin carrying oxygen through the blood. If it is less than 90 percent, you should see a doctor.
- 28.
- 29. Cyanosis of the tissue in the hand
- 30. Fallacies &Inaccuracies occur when: Misplaced onthepts finger, slipped. Pt movement, shivering. Tissue perfusion (cold extremities) →warmthept, put a glove filled withwarmwater in thepts hand (always avoid hypothermia). Cardiac arrest.
- 31. Rules Keep thesound ofthepulse oximeterON at all times. ALWAYS Remember thatyourclinical judgement is muchmore superiortothe monitor.Check ptcolourforcyanosis: lips, nails. Ifhypoxemiaoccurs immediately check theptscolour : nails &lips, thenmanageaccordinglyandcallforhelp.
- 32. (3) Blood Pressure Timing of BP monitoring :throughout the surgery. Frequency of measurement: By default every 5 minutes. Every 3 minutes: immediately after spinal anesthesia. Every 10 minutes: eg. Inawake pts under local anesthesia.
- 33. Reading errors/Failures Pressure line is disconnected. Leakage from damaged cuff. Line is compressed (under someone’s foot or under a weal). Line contains water from washing!
- 34. How to Attach Correct cuff size : width of the cuff should be 1.5 times limb diameter and should occupy at least 2/3 of the arm. 2 cuff sizes for adult: blue : for most adult individuals (60-90 Kg), red : for morbid obese. Selection of appropriate cuff size is importantbecause a tight cuff leads to false high readings, while a L oose cuff gives false Low readings.
- 35. IBP: Itis beat tobeat monitoringofABP via an arterial cannula. Indicated in: major surgeries, cardiac surgery, in surgeries involving extreme hemodynamic changes/instability eg. Pheochromocytoma.
- 36. (4) Capnography Definition Continuous CO2 measurement displayed as a waveform sampled fromthe patient’s airway during ventilation. Normal range: 35-40mmHg What is EtCO2? A point onthecapnogram. Itis thefinal measurement at theendpointofthepts expiration before inspiration begins again. Itis usually thehighest CO2 measurement during ventilation.
- 37. Terminology Capnography:- A real time waveform recorded of the concentration of carbon dioxide in the respiratory gases. Capnogram:- it is waveform + numeric value.
- 38.
- 39. Phases of the capnogram: A-B End of inspiration B-C Beginning of expiration C-D Alveolar plateau D-E Beginimg of new breath E-A End of inspiration
- 40. Factors that affect CO2 levels Increase in ETCO2 Decrease in ETCO2 Increased muscular activity Decreased muscular activity Increased cardiac output Decreased cardiac output hypoventilation Hyperventilation Partial airway obstruction Pulmonary embolism
- 41. Individual system monitering Respiratory System. CNS: Awareness. Temperature. Monitoringafter Extubation & Recovery.
- 42. Respiratory monitoring Clinical monitoring: Colour: cyanosis : nails, lips, palms, conjunctiva. Chest rise &fall (inflation). Ventilator sound : duringrespiratory cycle. Abnormal sounds eg. leakage, disconnection, highairway pressure.
- 43. CNS Awareness Clinical monitoring: Signs ofptawareness: Movement, grimacing (facial expression) Pupils dilated. Lacrimation. Tachycardia. HTN. Sweating : is always an alarming/warningsign. Causes Hypoglycemia. Hypercapnia. Thyroid storm (thyrotoxic crisis). Fever.
- 44. Temperature monitoring Clinical monitoring : urhands. Monitors : temperature probe: esophageal, nasopharyngeal.
- 46. Nasopharyngeal
- 47. Complications of hypothermia Cardiac arrhythmias: VT & cardiac arrest. Myocardial depression. Delayed recovery (delays drug metabolism). Coagulopathy.
- 48. How to avoid hypothermia: Warm IV fluids. Intermittently switching off air- conditioning esp. towards the end ofsurgery ( ↑ ambient roomtemp). Pediatrics: warming blanket.
- 49. Monitoring after extubation and recovery After extubation : immediately fit the face mask on theptand observe thebreathing bag Good regular breathing with adequate tidal volume transmitted tothebag. No transmission tothe bag →respiratory obstruction SpO2: ˃ 92% Breathing : regular. Level of consciousness : fully conscious. 1) obeying orders, 2) eye opening, 3) purposeful movement. Most IMP: Pt must be able to protect his ownairway.
- 50. To summarize The 4 basic monitors displayed on the screen: 1 ) ECG. 2) BP. 3) SpO2. 4) ± Capnogram (EtCO2).