3ASA Monitoring Guidelines Standard I:Qualified anaesthesia personnel shall be present in the room throughout the conduct of all general anaesthetics, regional anaesthetics and monitored anaesthesia care.Standard II:During all anaesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.
5Who is the best Monitor in the operating room? The AnaesthesiologistThe monitors however extend their range and increase their efficacy.
6Clinical Monitoring of Cardiovascular system Inspection, palpation and auscultation are fundamental elements of perioperative cardiovascular monitoring.Inspection :Mucous membranes, Skin color and Skin turgor provide clues about hydration, oxygenation and perfusion.PallorCyanosis (peripheral/ central)
7Inspection of neck veins s/o low, normal or high JVP.Elevated JVP:Congestive heart failure, Cor pulmonalePulmonary embolism, TamponadeIatrogenic fluid overload in surgical patients.Right ventricular infarctionSimple clinical techniques like:Empirical estimation of fluid deficits and blood loss.Measurement of urine outputDetection of altered mental status.
8Palpation of accessible peripheral pulse Coldness of extremities: sign of reduced cardiac output.Oedema : Pitting oedema is a cardinal feature of CHF.Palpation of accessible peripheral pulseExamination of cardiac rate and rhythm:Tachycardia : light anaesthesia, hypotension drug induced (atropine, glycopyrrolate).Bradycardia : increased vagal tone, inhalant anaesthetic overdose.Irregular rhythm: Atrial fibrillation, frequent ectopic beats or self limiting paroxysmal arrhythmias.
9Pulse characteristics Bounding pulse: Hyperdynamic circulation Slow rising: Aortic stenosisWater hammer: Aortic regurgitationBifid pulse: HOCM, severe AR, AS+ ARDicrotic pulse: severe Heart failurePulsus alternans: Heart failureSymmetry : Radial, Brachial, Carotid, Femoral, Popliteal and pedal pulses .Reduced or absent pulse indicates obstruction proximally in arterial tree usually by thromboembolism or aortic dissection.
10Auscultation/ Stethoscopy: Palpation of any artery within the surgical field by the surgeon in case of hemodynamic instability.Capillary Refill Time : normal < 2 sec.>2 sec. suggestive of inadequate tissue perfusion.Auscultation/ Stethoscopy:Intraoperative monitoring with either precordial or esophageal stethoscope are the most common simple methods for monitoring circulation and ventilation in anaesthetized patients.2 types: Precordial Esophageal
11Precordial stethoscopy 2 types: Precordial EsophagealPrecordial stethoscopySimple, highly effective device.Monitors heart and respiratory functionHeavy metal bell or accumulator attached to length of rubber or plastic extension tubing and monoaural earpiece.Electrically amplified stethoscope available which improve quality and clarity of heart and breath sounds.
13Esophageal Stethoscopy Soft, plastic catheter with a balloon covered distal opening. Tip placed at junction of middle and lower third of esophagus
14Advantages of esophageal stethoscopy Breath and heart sounds heard clearly.Detects apnea, myocardial depression, arrythmias, endobronchial intubation, airway secretions, wheeze, air embolus etc.Temperature probe, ECG leads and atrial pacemaker electrodes can be incorporated.Limitation: can be used only in intubated patients
15Complications Hypoxemia : Unintended tracheobronchial placement or compression of membranous posterior trachea in infants.Loss down the esophagusDetachment of accoustic cuffContraindication: Esophageal varices or stricturesThe current role of intra operative stethoscopy as a continuous monitor has become limited to special applications (Pediatric Anaesthesia and to institutions with limited resouces).
16Heart Rate / Pulse Rate Monitoring Heart Rate measured from the ECG trace and Pulse Rate from a selectable pulse source, most common being pulse oximeter/IABP waveform / Automatic NIBP.Problems in HR monitoring: interference by artifacts caused by electrosurgical unit.Paced rhythms can cause problems.Pulse oximeter is of limited value in pts. with arterial occlusive disease or peripheral vasoconstriction.Pulse deficit – extent to which pulse rate is less than the heart rate. Example Atrial fibrillation, Electrical – mechanical dissociation or Pulseless electrical activity.
17Blood PressureForce exerted by circulating blood against any unit area of the vessel wall.One of the principal vital signDepends on the Cardiac output and Peripheral resistance.Blood Pressure Monitoring: Indirect cuff devices Direct arterial cannulation and pressure transductionNoninvasive BP monitoring:Manual Intermittent techniquesAutomated Intermittent techniquesAutomated Continuous techniques
18Manual Intermittent Techniques: Palpatory AuscultatoryPalpatory methodsRely on sphygmomanometer and mercury manometer to measure cuff pressureRiva- Rocci method: SBP measured by determining pressure at which palpated radial pulse disappeared as cuff was inflated.Return to flow technique: variation of Riva-Rocci method.SBP recorded during cuff deflation at which pulse reappears and is detected by palpation.Can be used with pulse oximeter or indwelling arterial catheter in ipsilateral arm.
19Auscultatory method Originally described by Korotkoff in 1905. Most commonly used.Uses Sphygmomanometer, cuff and stethoscope.Measures both SBP and DBP by auscultating sounds produced by arterial blood flow.Korotkoff sounds:Very low frequency sounds (25-50 Hz) produced by turbulent blood flow beyond the partially occluded cuff.Failure to identify initial Korotkoff sounds results in falsely low BP.
20Phases of Korotkoff sounds: 1.First appearance of sounds marking SBP. II and III- Increasingly loud sounds.IV. Abrupt muffling of soundsV. No soundsPhase V provides better measure of DBP.Phase IV may be used in conditions where Korotkoff sounds remain audible despite complete deflation of cuff.Eg. AR, AV fistula and pregnancy.
21Technical aspects Length of the cuff should be 80% and width should be 40% of the circumference of thearm.Cuff should be applied snugly, with bladder centred over the artery.Rate of cuff deflation should be 2-3mmHg per heart beatMiscuffing:Use of inappropriate sized cuffs.Most common source of error .Too small cuff leads to false high BP and too large cuff will produce little error .
22Adequate size of cuffs size Arm circumference (cm) Bladder size Newborn6-112.5x5Infant10-196x12Child18-269x18Adult25-3512x23Large arm33-4715x33Thigh46-6618x36
23Limitations of auscultatory method Conditions of decreased peripheral flow or high dose vasopressor infusion can attenuate the sounds and underestimate the BP.Shivering decreases compliance of tissues under the cuff leading to Pseudohypertension.BP RELIES ON BLOOD FLOWHIGH OCCLUDING PRESSURE NEEDED
24Discrepancy between Direct and Indirect BP measurements in shock (from Cohn JN. Blood pressure measurement in shock. JAMA 1967)Systolic BP Difference(Direct – Cuff)% Patients0-10 mm Hg11-20 mm Hg2821-30 mm Hg22>30 mm Hg50
25Automated Intermittent Techniques (Oscillometry) Provide frequent, regular BP measurement.Utilize the Oscillometry principle.Arterial pulsation —› variation in cuff pressure during cuff deflation —› sensed by sensor —› used to measure BP.Point of maximum amplitude of arterial pulsations corresponds to MAP.SBP and DBP calculated from increasing and decreasing magnitude of oscillations acc. to empirically derived algorithm.
26SBP identified as pressure at which pulsations are increasing and are at 25-50% of the maximum. DBP is the most unreliable oscillometric measurement.Advantages:Uniform compression of the artery is not necessaryNo interference with noiseNot sensitive to electrosurgical interferenceWork well with peripheral vasoconstrictionLimitation : sensitive to patient’s arm movement.
28Factors affecting BP determination Cuff arm relationship: too small cuff overestimates BP.Site: cuff placed peripherally leads to increased SBP and decreased DBP.Arm Position: each 10cm vertical height above or below heart level, 7.5mm Hg should be added or subtracted.Arrhythmias: vulnerable to error.
29Complications of non invasive BP measurement PainPetechiae and ecchymosis (patients on anti inflammatory drugs, steroids, anticoagulants)Limb edemaVenous stasis and thrombophlebitisPeripheral neuropathy (median, ulnar, radial)Compartment syndrome (more common after prolonged periods of frequent cycles of measurement, trauma or impaired limb perfusion)
30Finger BP measurement (Finapress) - Automated continuous technique Finger BP measurement (Finapress) - Automated continuous technique. -Uses Penaz technique(arterial volume clamp method). - Device tends to track the MAP in digital arteries underlying the cuff by keeping the volume of the finger constant and thus nulling the transmural pressure. -Waveform displayed on screen.
31Advantages:It is an attempt to improve on the rapidity of determination of NIBPCorrelates well with invasive BP in patients not in shock.Disadvantages:Compression of digital veins leads to suffusion of finger, temporary numbness.Less reliable when peripheral perfusion decreased.Very sensitive to correct placement on middle phalanx.
32Vasotrac system Most advanced BP measurement device Vasotrac system Most advanced BP measurement device. Accurately measures SBP, DBP, MAP by waveform analysis. Continuous, non invasive. Variable pressure applied by pressure sensing mechanism directly over artery. Counterpressure in artery produces waveform.
33Invasive BP Monitoring Arterial cannulation with continuous pressure transduction with waveform display is the accepted reference standard for BP monitoring.Catheter over needle technique by Barr in
34Indications for Direct Arterial BP Monitoring Small change in arterial perfusion pressure increases patient’s risk requiring beat to beat assessment (CAD, valvular heart disease).Wide variation in BP or intravascular volume is anticipated.Frequent blood sampling, especially ABG analysis is required.Assessment of BP can’t be done by other methods. Eg. – Cardiopulmonary bypass (nonpulsatile flow), dysrhythmias, marked obesity.
35ContraindicationsLocal infectionCoagulopathy: may result in hematoma formation.Proximal obstruction: Thoracic outlet syndrome, Coarctation of aorta.Raynaud’s syndrome and Buerger’s disease
39Alternative sites for arterial pressure monitoring Ulnar arteryBrachial arteryDorsalis pedis, Posterior tibial artery( generally for pediatric patients , Neurosurgery) and superficial temporal artery.Axillary artery and Femoral artery (safe, comfortable but increased risk of atherosclerotic embolization)Ulnar art safe. Brac art longer cath pref, safe. Other periph sites incl dp pt art. Reasonable altern to radial art espec in neurosurg. Modif allens test can be performed . Axill and femor art are consid safe ,comfortable but have incr risk of atheroscl embolization
41Complications of arterial pressure monitoring Distal ischemia (0.1%)Pseudoaneurysm, arteriovenous fistula.Hemorrhage, hematomaArterial embolizationLocal infection, sepsisPeripheral neuropathyMisinterpretation of data (equipment misuse)Factors for ischemia-vasospas arter ds, prev arter inj , thrombocytosis, shock, high dose vasopressor , prolonged cannulation,infection. Additional rare complications mostly assoc with technic prob or confounding medical problems. Last pt mostly attributed to equipment misuse.
42Arterial Pressure waveform Results from ejection of blood from the LV into aorta during systole f/b peripheral arterial runoff of SV during diastole.Systolic components follow R wave in ECG.Consists of:Steep Pressure upstrokePeakDecline
43Downslope interrupted by dicrotic notch, then continues to decline during diastole after T wave of ECG. Dicrotic notch directly in central aorta is called incisura(rel. to closure of aortic valve). Systolic upstroke of radial artery trace msec after R wave of ECG (time to travel from heart to radial artery to transducer). MAP by area under arterial pressure wave divided by beat period.3rd pt this reflects sum of times reqd for spread of wave from heart to periph radial art to transducer.
44Distal Pulse Amplification Central Aorta to periphery: - Arterial upstroke becomes steeper - Systolic peak higher - Dicrotic notch appears later - Diastolic wave more prominent - End diastolic pressure becomes lowerOne of imp featuresof iabp waveform is phenom ofAs arter pulse wave travels from
45Arteriolar level is major site of resistance to blood flow Arteriolar level is major site of resistance to blood flow. Causes augmentation of upstream pressure pulsations because of wave reflection.
47Interpretation of Arterial tracings Contains a great deal of hemodynamic information.Heart rate and rhythm: role in patients with pacemaker or electrocautery which can distort ECG.Pulse pressure: information about fluid status and valvular competence .Respiratory variation and volume status
48Qualitative estimation of hemodynamic indices Qualitative estimation of hemodynamic indices Contractility: rate of pressure rise during systoleStroke volume: area under aortic pressure curveVascular resistance: presence of dicrotic notch
49Components of IABP system Intra-arterial cannulaCoupling systemPressure transducerInfusion flushing systemSignal processor, amplifier and display
51Components of IABP measurement system Intra arterial cannula:Short, narrow cannula (20G or smaller) made of Teflon to decrease risk of arterial thrombus formation.Risk of arterial thrombus directly proportional to diameter of cannula.Coupling system:Consists of pressure tubing, stopcocks and a continuous flushing device.Tubing should be short, wide and non-compliant (stiff) to reduce damping.Major source of distortion of arterial pressure tracings.
52Pressure TransducerThe device that converts the Intra arterial pressure into an electrical signal.A critical part of transducer is the diaphragm which acts to link fluid wave to the electrical input.When the diaphragm is distorted by a change in pressure, voltages are altered across the variable resistors of wheatstone bridge contained in the transducer.This in turn produces change in current which is electrically converted and displayed.Most transducers are of resistance type. Has stiff, low compliance pressure sensing diaphragm. Works basically on wheatstone bridge principle.
53Wheatstone bridgeConsists of a common source of elect current and galvan that connects 2 paral branches cont 4 resistors. Strain gauge transforms strain into proport change in resistance . 4 strain gauges form 4 resistorsof ws bridge. Resist of 2 strain gauges on opp sides inc and other 2 dec. change in resis meas along with current , electr conv and displayed as systolic dias and map.
54Infusion/ flushing system: Plain 0.9% saline pressurized to 300 mmHg and connected to fluid filled tubing via flush system.Slow infusion at 1-3 ml/hr to maintain patency.Intermittent flushing with 2-3ml can be done.Dilute concentration of heparin (1-2 U/ml). Adverse effect- Heparin induced ThrombocytopeniaSignal processor, amplifier and display:Signal relayed by pressure transducer to microprocessor which filters, amplifies, analyses and displays it as waveform of Pressure vs Time.
55Characteristics of Pressure measurement system Blood pressure monitoring systems are described as underdamped, second order dynamic systems.2 important system parameters are:Natural frequency quantifies how rapidly a system oscillates.Damping coefficient quantifies the frictional forces that act on system and determine how frequently it comes to rest.Both must be estimated bedside as they influence the appearance of recorded wave and thus interpretation.Both parameters must be estimated bedside as they influence the appearance of recorded wave and thus interpretation
56Fourier analysis Fourier Analysis: Process of analysing a complex waveform in terms of constituent sine waves.Arterial waveform can be broken up into a series of component sine waves with different amplitudes and frequenciesArterial pressure wave consists of a fundamental wave (pulse rate) and a series of harmonic waves (smaller waves whose frequencies are multiples of fundamental freq.)Crude arterial waveform can be reconstructed with 2 sine waves, fundamental frequency and second harmonic.6-10 harmonics required for distortion free reproduction of arterial waveforms.
57Damping: tendency of factors like friction, compliant tubing and air bubbles to absorb energy and decrease amplitude of peaks and troughs in waveform.Optimal damping: which counterbalances distorting effects of transducer tubing system with lower natural frequency.Most catheter transducer systems are underdamped but have acceptable Natural frequency (> 12 Hz).Lower the natural frequency, more narrow the range of damping coefficients can be tolerated to ensure correct reproduction of pressure waves..
58Natural frequency should be high for optimal Dynamic response . Achieved by:Short lengths of stiff pressure tubingLimiting the number of stopcocksRemove any blood clots or air bubbles.
59Overdamped arterial pressure waveform Overdamped arterial pressure waveform has slurred upstroke, absent dicrotic notch and loss of fine details.Features : slurred upstroke, absent dicrotic notch and loss of fine details.Consequence : false low BP.
60Underdamped arterial pressure waveform Underdamped waveforms have systolic pressure overshoot and artifacts.Features: systolic pressure overshoots and artifactsConsequence : Difficult to discern dicrotic notchNo significance of artifact waves
64Fast Flush testFlush the system with high pressure saline or with 2-3 ml saline.Frequency determined by measuring period of one cycle of adjacent oscillation peaks.Uses :Restores the dynamic characteristics of the pressure monitoring system.Measure the Natural frequency and Damping coefficient.Used to purge the extension line of blood after arterial sampling.
65Transducer setups Zeroing: Done by exposing the transducer to atmospheric pressure and calibrating pressure reading to zero.Air fluid interface at level of stopcock is the zero pressure locus.Ambient atmospheric pressure should be the reference against which all intravascular pressures are measured.Last pt idea behind this is that…as atmospheric press has equal effect on both bld vsl and transducer
66Levelling:Pressure transducer must be set at appropriate level to best estimate aortic root pressure.Usually taken to a level with patient’s heart at 5 cm posterior to the sternal angle.CalibrationCurrent disposable transducers do not require calibration.
69Arterial pressure monitoring for predicting fluid responsiveness Dynamic markers of fluid responsivenessUseful in determining end points for fluid resuscitation.Variations in ABP during positive pressure ventilation- most widely used indicator.Systolic pressure variationPulse pressure variation
70Systolic pressure variation Positive pressure inspirationIncreasing lung volume compresses pulmonary venous reservoirBlood propelled into left heart chambersLV preload increased
71Increase in intrathoracic pressure decreases LV afterload Increased LV Stroke volume and systemic arterial pressureSimultaneously RV preload and afterload increased
72Decreased RV stroke volume during inspiration During expiration, reduced RV stroke volume crosses pulmonary bed and decreases LV fillingLV stroke volume and arterial BP falls.Cyclic variation known as Systolic Pressure Variation (SPV)
73SPV divided into inspiratory and expiratory components by measuring increase (∆ up) and decrease (∆ down) in systolic pressure in relation to End expiratory apneic baseline pressure.Normal SPV in mechanically ventilated patient is 7-10mmHg (∆ up 2-4mmHg and ∆ down 5- 6mmHg).Hypovolemia causes drastic increase in SPV, particularly ∆ down component even if arterial BP is maintained by peripheral vasoconstriction.Large SPV may be s/o low PAWP.∆ up may suggest afterload dependence of LV.
75Pulse Pressure variation Another dynamic indicator of volume responsiveness.Maximal difference in arterial pulse pressure over the course of positive pressure respiratory cycle divided by average of maximum and minimum pulse pressure.Normal not more than 13%.Other indicators:Stroke volume variation (normal 10%)Respiratory cycle induced variation in pulse plethysmogram.
77Limitations of dynamic indicators Magnitude of BP variation influenced by Tidal volume and Peak inspiratory pressure.SPV and PPV not reliable in patients with cardiac arrhythmias and changes in chest wall or lung compliance.Validated only for mechanically ventilated patients.
78SUMMARYContinuous stethoscopy is an insensitive method for the early detection of untoward cardiovascular events.In auscultatory method flow turbulence under the cuff is used for measuring BP.Automatic measure of NIBP includes Oscillometry, Microphonic detection of korotokoffs sounds and Finapress.Oscillometry method measures MAP more effectively.
79Direct IABP is widely used because hazards related to the technique is low, provides a continuous input of information and also detects changes in cardiovascular function and intravascular volume.The Allens test is not a reliable method to predict complications and other better alternatives include use of doppler and pulse oximeter probe.The most common route of bacterial infection in IABP set up is from the nonsterile transducer to the patient access- stopcock via health professionals fingers.
80Liquid or gas sterilization is appropriate for transducer. Dynamic measures of cardiac preload are better predictor of volume responsiveness than static indicators such as CVP or PCWP.
81References Hutchison’s clinical methods. 21st edition Miller’s Anaesthesia. 7th editionUnderstanding Anaesthesia equipments. Dorsch and Dorsch. 5th editionMonitoring in anaesthesia and critical care medicine. Blitt. 2nd editionThe ICU book. Paul Marino. 3rd edition.Kaplan’s Cardiac Anaesthesia.