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Monitoring in Anesthesia พญ. เพชรรัตน์ วิสุทธิเมธีกร พ. บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว.( วิสัญญี ) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร.

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Presentation on theme: "Monitoring in Anesthesia พญ. เพชรรัตน์ วิสุทธิเมธีกร พ. บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว.( วิสัญญี ) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร."— Presentation transcript:

1 Monitoring in Anesthesia พญ. เพชรรัตน์ วิสุทธิเมธีกร พ. บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว.( วิสัญญี ) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร และวชิรพยาบาล

2 Topic module  1. รู้วัตถุประสงค์และความสำคัญ ในการเฝ้าระวัง  2. รู้จักข้อบ่งชี้และขัอห้ามในการ ใช้เครื่องเฝ้าระวัง  3. สามารถใช้และแปรผลค่าที่ได้ จากเครื่องเฝ้าระวัง ( NIBP, SpO2, ECG, ET-CO2 )

3 Contents  Introduction  What is monitoring?  Which, Why and How to monitor?  Level of monitoring  Standards for basic intraoperative monitoring ( ASA)  Systematic monitoring  Conclusion

4 Monitoring: A Definition ... interpret available clinical data to help recognize present or future mishaps or unfavorable system conditions ... not restricted to anesthesia (change “clinical data” above to “system data” to apply to aircraft and nuclear power plants )

5 What is monitoring?  to monere ( การเฝ้าระวัง, การเตือนภัย )  Physiologic parameter & Patient safety parameter  Clinical skills & Monitoring equipment  Data collection, interpretation, evaluation, decision  Problem seeking, Severity assessment, Therapeutic assessment, Evaluation of Anesthetic interventions

6 Patient Monitoring and Management Involves …  Things you measure (physiological measurement, such as BP or HR)  Things you observe (e.g. observation of pupils)  Planning to avoid trouble (e.g. planning induction of anesthesia or planning extubation)  Inferring diagnoses (e.g. unilateral air entry may mean endobronchial intubation)  Planning to get out of trouble (e.g. differential diagnosis and response algorithm formulation)

7 Level of monitoring  Routine / Specialize / Extensive  Non-equipment / Non-invasive / Minimally invasive / Penetrating / Invasive / Highly invasive  Systematic  Respiratory / Cardiovascular / Temperature/Fetal  Neurological / Neuro-muscular / Volume status & Renal  Standards for basic intraoperative monitoring ( ASA)

8 Standards for basic intraoperative monitoring ( ASA : American Society of Anesthesiologists) Standard I  Qualified anesthesia personnel shall be present in the room throughout the conduct of all GA, RA, MAC Standard II  During all anesthetics, the patient’s respiratory (ventilation, oxygenation), circulation and temperature shall be continually evaluated

9 Monitoring in the Past  Visual monitoring of respiration and overall clinical appearance  Finger on pulse  Blood pressure (sometimes)

10 Monitoring in the Past Finger on the pulse

11 Harvey Cushing Not just a famous neurosurgeon … but the father of anesthesia monitoring  Invented and popularized the anesthetic chart  Recorded both BP and HR  Emphasized the relationship between vital signs and neurosurgical events ( increased intracranial pressure leads to hypertension and bradycardia )

12 Examples of Multiparameter Patient Monitors

13 Some Specialized Patient Monitors Depth of Anesthesia Monitor Evoked Potential Monitor Transesophageal Echocardiography

14 Cardiovascular monitoring  Routine monitoring  Cardiac activity  Non-invasive blood pressure ( NIBP )  Electrocardiography ( ECG )  Advanced monitoring  Direct arterial blood pressure  Cardiac filling pressure monitor  Central venous pressure  Pulmonary capillary wedge pressure

15 Cardiovascular monitoring  Electrocardiography  Cardiac activity  Arrhythmia: Lead II  Myocardial ischemia: ECG criteria  Electrolyte imbalance  Pacemaker function

16 Cardiovascular monitoring  การบ้าน ECG 1. การติด lead II, modified V5 2. การแปรผล สาเหตุ การรักษา -arrhythmia : bradycardia, tachycardia, AF, PVC, VT, VF -Myocardial ischemia -electrolyte imbalance

17 Cardiovascular monitoring  Non-invasive blood pressure (NIBP)  Cuff: width % limb diameter, air bladder includes more than halfway around limb  Manometer: aneroid, mercury  Detector: manual, automated การบ้าน หลักการทำงาน หลักการเลือกขนาด ค่าที่ได้ ค่าใดถูกต้องและเชื่อถือได้มากที่สุด สถานะการณ์ใดรบกวนการวัดและรบกวนอย่างไร

18 Cardiovascular monitoring  Non-invasive blood pressure  Inaccurate: cuff size, inflated pressure, shivering, cardiac arrhythmia, severe vasoconstriction Proper applicationNarrow cuffLoose cuff

19 Cardiovascular monitoring  Direct arterial pressure monitor  Indications  Continuous blood pressure monitor: anticipated cardiovascular instability, direct manipulation of cardiovascular system, inability to accurate measurement directly  Frequent arterial blood sampling: ABG, Acid- base / electrolyte / glucose disturbance, Coagulopathies

20 Cardiovascular monitoring  Direct arterial pressure monitor  Contraindications  Local infection  Impaired blood circulation: Raynaud’s phenomenon, DM  Risks of thrombosis: hyperlipidemia, previous brachial artery cannulation  Modified Allen’s test ??? ( การบ้านข้อที่ เท่าไรแล้วคะ )

21 Cardiovascular monitoring  Direct arterial pressure monitor  Complications  Direct trauma: AV-fistula, Aneurysm  Hematoma  Infections  Thrombosis  Embolization  Massive blood loss

22 Cardiovascular monitoring  Cardiac filling pressure monitor  Frank-Starling curve: optimum Preload maximize ventricular performance (Stroke volume, CO.)  Preload = Myocardial fiber length (2.2 micron)  LV Preload  LVEDV  LVEDP  LAP  PCWP  PAP  RVP  RAP  CVP  Myocardium function, LV compliance, Mitral valve, Airway pressure, Pulmonary vascular resistance, Pulmonic valve, Tricuspid valve

23 Cardiovascular monitoring  Cardiac filling pressure monitor  LV Preload  LVEDV  LVEDP  LAP  PCWP  PAP  LVEDP  RVEDP  RAP  CVP

24 Cardiovascular monitoring  Cardiac filling pressure monitor  PCWP: Pulmonary capillary wedge pressure  CVP: Central venous pressure

25 Cardiovascular monitoring  PCWP: Pulmonary capillary wedge pressure  CVP: Central venous pressure  Fluid Challenge test  Fluid Challenge test to optimize preload and maximize Cardiac performance

26 Respiratory monitoring  Ventilatory monitoring  Oxygenation monitoring  Machine and Circuit monitoring  Clinical skills  Monitoring devices

27 Ventilatory monitoring  Clinical skills  Direct observation: rate, rhythm, volume of respiration  Auscultation: precordial, esophageal stethoscope  Palpation: reservoir bag movement  Monitoring devices  Spirometer  Airway pressure manometer  Circuit disconnection alarm

28 Ventilatory monitoring (End-tidal CO 2 analysis  Capnometer (End-tidal CO 2 analysis )  relationship with PaCO 2 : ETCO 2 < PaCO 2 ~ 3-6 mmHg  mainly depends on dead space ventilation  normal value 30 – 35 mmHg  Infrared absorption spectrography  Main-stream VS. Side-stream

29 Ventilatory monitoring  Capnogram : normal curve  1. Dead space air (no CO 2 )  2. Mixed bronchus & alveolus air (CO 2 upstroke)  3. Alveolus air (CO 2 plateau) Inspiration ETCO

30 Ventilatory monitoring  Capnometer (End-tidal CO 2 analysis)  Most useful in detection of Esophageal intubation, airway or circuit disconnection  Useful in CO 2 rebreathing, partial recovery of neuro- muscular blockade, good predictor of successful CPR

31 การบ้าน ( เขียน waveform of ET-CO2 และสาเหตุ )  Capnograph -esophageal intubation -bronchial intubation -airway obstruction -circuit disconnect -circuit leakage -partial rebreathing -spontaneous breathing (recovary of neuromuscular blockade) -hypoventilation

32 Oxygenation monitoring  Clinical skills  Direct observation: impaired mental function, sympathetic overactivities, appearance(+ cyanosis)  Auscultation: wheezing, crepitation  Monitoring devices  Arterial blood gas analysis  Percutaneous O 2 measurement  Pulse oximeter

33 Oxygenation monitoring  Pulse oximeter  Percent of oxyhemoglobin / total hemoglobin  Oxyhemoglobin absorp 940 nm.  Deoxyhemoglobin absorp 660 nm.  Caution: SpO 2  PaO 2

34 Oxygenation monitoring  Pulse oximeter  SpO 2 correlates with PaO 2 as in Oxygen-hemoglobin dissociation curve  SpO 2 90  PaO 2 60 mmHg (moderate hypoxemia) 75  40 mmHg (mixed venous oxygen sat.) 50  27 mmHg (P 50 )

35 Oxygenation monitoring  Pulse oximeter artifacts  Abnormal hemoglobin: COHb, MetHb, HbF  Dye: Methylene blue  Anemia  Ambient light  Arterial saturation  Blood flow  Motion  Nail polish  Electro-cautery

36 การบ้าน  Wave form Pulse oximeter  Pulse oximeter artifacts กระทบต่อการ แปรผลอย่างไร  Cause of Rt-Lt shift of oxygen- hemoglobin dissociation curve

37 Machine & circuit monitoring  Safety system  DISS, PISS, Quick disconnection adaptor  Oxygen fail-safe valve, Oxygen supply failure alarm  Oxygen analyzer  Airway gas composition  Clinical skills: flowmeters, vaporizers  Monitoring devices: Infrared spectrometer

38 Depth of Anesthesia  Clinical Signs  eye signs  respiratory signs  cardiovascular signs  CNS signs  EEG monitoring  Facial EMG monitoring (experimental)  Esophageal contractility (obsolete)

39 Neurologic monitoring  Depth of anesthesia ( BIS )  EEG  Evoked potentials  Cerebral blood flow  Intracranial pressure

40 Neuromuscular monitoring  Clinical skills  Monitoring device : PERIPHERAL NERVE STIMULATOR

41 Volume status and renal monitoring  Estimate blood loss  Urine output  Hemodynamic stability

42 Volume status and renal monitoring  Estimate blood loss  Urine output  Hemodynamic stability

43 Electrolyte / Metabolic monitoring  Fluid balance  Sugar  Electrolytes  Acid-base balance

44 Coagulation Monitoring  PT / PTT / INR  ACT  Platelet counts  Factor assays  TEG  Clinical sign

45 Temperature monitoring  4 mechanism of heat loss  Perioperative hypothermia (BT<36)  Core temperature : nasopharynx, esophageal, tympanic membrane, pulmonary a. catheter, bladder, rectum

46 Temperature Monitoring Rationale for use  detect/prevent hypothermia  monitor deliberate hypothermia  adjunct to diagnosing MH  monitoring CPB cooling/rewarming

47 Temperature monitoring  Deleterious effects of hypothermia -cardiac dysrhythmia -increased PVR -Lt. shift of the Oxygen-hemoglobin dissociation curve -reversible coagulopathy (platelet dysfunction) -postoperative protein catabolism and stress response -altered mental status -impaired renal function -decreased drug metabolism -poor wound healing

48 Conclusion การบ้านกี่ข้อแล้วคะ มีเครื่องมือเยอะจัง ไม่ได้อย่า out ต้องรู้ NIBP,ECG,ET- CO2,SpO2


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