1. INTRODUCTION TO PATIENT MONITORING D. John Doyle MD PhD FRCPC Cleveland Clinic Foundation Revision 1.1 33 Slides January 2006 STA Patient Monitoring INTRODUCTION Vol 1 Rev 1.1.ppt

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

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

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

5. Monitoring in the Past Finger on the pulse

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

7. Monitoring in the Present Standardized basic monitoring requirements (guidelines) from the ASA (American Society of Anesthesiologists), CAS (Canadian Anesthesiologists’ Society) and other national societies Standardized basic monitoring requirements (guidelines) from the ASA (American Society of Anesthesiologists), CAS (Canadian Anesthesiologists’ Society) and other national societies Many integrated monitors available Many integrated monitors available Many special purpose monitors available Many special purpose monitors available Many problems with existing monitors (e.g., cost, complexity, reliability, artifacts) Many problems with existing monitors (e.g., cost, complexity, reliability, artifacts)

8. ASA Monitoring Guidelines STANDARD I Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.http://www.asahq.org/publicationsAndServices/standards/02.pdf

9. ASA Monitoring Guidelines STANDARD II During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.http://www.asahq.org/publicationsAndServices/standards/02.pdf

10. “The only indispensable monitor is the presence, at all times, of a physician or an anesthesia assistant, under the immediate supervision of an anesthesiologist, with appropriate training and experience. Mechanical and electronic monitors are, at best, aids to vigilance. Such devices assist the anesthesiologist to ensure the integrity of the vital organs and, in particular, the adequacy of tissue perfusion and oxygenation.” CAS Monitoring Guidelines

11. The following are required: The following are required: Pulse oximeter Pulse oximeter Apparatus to measure blood pressure, either directly or noninvasively Apparatus to measure blood pressure, either directly or noninvasively Electrocardiography Electrocardiography Capnography, when endotracheal tubes or laryngeal masks are inserted. Capnography, when endotracheal tubes or laryngeal masks are inserted. Agent-specific anesthetic gas monitor, when inhalation anesthetic agents are used. Agent-specific anesthetic gas monitor, when inhalation anesthetic agents are used. CAS Monitoring Guidelines

12. The following shall be exclusively available for each patient: The following shall be exclusively available for each patient: Apparatus to measure temperature Apparatus to measure temperature Peripheral nerve stimulator, when neuromuscular blocking drugs are used Peripheral nerve stimulator, when neuromuscular blocking drugs are used Stethoscope — either precordial, esophageal or paratracheal Stethoscope — either precordial, esophageal or paratracheal Appropriate lighting to visualize an exposed portion of the patient. Appropriate lighting to visualize an exposed portion of the patient. CAS Monitoring Guidelines

13. The following shall be immediately available: The following shall be immediately available: Spirometer for measurement of tidal volume. Spirometer for measurement of tidal volume. CAS Monitoring Guidelines

14. Detecting Mishaps Using Monitors 1. Disconnection 2. Hypoventilation 3. Esophageal intubation 4. Bronchial intubation 5. Circuit hypoxia 6. Halocarbon overdose 7. Hypovolemia 8. Pneumothorax 9. Air Embolism 10. Hyperthermia 11. Aspiration 12. Acid-base imbalance 13. Cardiac dysrhythmias 14. IV drug overdose Source: Barash Handbook These mishaps …

15. Detecting Mishaps with Monitors Pulse oximeter Pulse oximeter Mass spectrometer Mass spectrometer Capnograph Capnograph Automatic BP Automatic BP Stethoscope Stethoscope Spirometer Spirometer Oxygen analyzer Oxygen analyzer EKG EKG Temperature Temperature1,2,3,4,5,8,9,11,141,2,3,6,9,10,121,2,3,9,10,126,7,9,141,3,4,131,2513 10 Source: Barash Handbook … are detected using these monitors

16. Basic Monitoring Cardiac: Blood Pressure, Heart Rate, ECG Cardiac: Blood Pressure, Heart Rate, ECG ECG: Rate, ST Segment (ischemia), Rhythm ECG: Rate, ST Segment (ischemia), Rhythm Respiratory: Airway Pressure, Capnogram, Pulse Oximeter, Spirometry, Visual Cues Respiratory: Airway Pressure, Capnogram, Pulse Oximeter, Spirometry, Visual Cues Temperature [pharyngeal, axillary, esophageal, etc.] Temperature [pharyngeal, axillary, esophageal, etc.] Urine output (if Foley catheter has been placed) Urine output (if Foley catheter has been placed) Nerve stimulator [face, forearm] (if relaxants used) Nerve stimulator [face, forearm] (if relaxants used) ETT cuff pressure (keep < 20 cm H 2 O) ETT cuff pressure (keep < 20 cm H 2 O) Auscultation (esophageal or precordial stethoscope) Auscultation (esophageal or precordial stethoscope) Visual surveillance of the anesthesia workspace and some exposed portion of the patient Visual surveillance of the anesthesia workspace and some exposed portion of the patient

17. Visual Surveillance Anesthesia machine / workspace checkout Anesthesia machine / workspace checkout Patient monitor numbers and waveforms Patient monitor numbers and waveforms Bleeding/coagulation (e.g., are the surgeons using a lot of suction or sponges? ) Bleeding/coagulation (e.g., are the surgeons using a lot of suction or sponges? ) Diaphoresis / movements / grimaces Diaphoresis / movements / grimaces Line quality (is my IV reliable?) Line quality (is my IV reliable?) Positioning safety review Positioning safety review Respiratory pattern (e.g. tracheal tug, accessory muscle use etc.) Respiratory pattern (e.g. tracheal tug, accessory muscle use etc.)

18. Low Tech Patient Monitoring Manual blood pressure cuff Manual blood pressure cuff Finger on the pulse and forehead Finger on the pulse and forehead Monaural stethoscope (heart and breath sounds) Monaural stethoscope (heart and breath sounds) Eye on the rebreathing bag (spontaneously breathing patient) Eye on the rebreathing bag (spontaneously breathing patient) Watch respiratory pattern Watch respiratory pattern Watch for undesired movements Watch for undesired movements Look at the patient’s face Look at the patient’s face color OK? color OK? diaphoresis present? diaphoresis present? pupils pupils

19. High Tech Patient Monitoring Examples of Multiparameter Patient Monitors

20. High Tech Patient Monitoring Some Specialized Patient Monitors Depth of Anesthesia Monitor Evoked Potential Monitor Transesophageal Echocardiography

21. Special Monitoring Pulmonary artery lines (Swan Ganz) Pulmonary artery lines (Swan Ganz) Transesophageal echocardiography Transesophageal echocardiography Intracranial pressure (ICP) monitoring Intracranial pressure (ICP) monitoring Electrophysiological CNS monitoring Electrophysiological CNS monitoring Renal function monitoring (indices) Renal function monitoring (indices) Coagulation monitoring (e.g. ACT) Coagulation monitoring (e.g. ACT) Acid-base monitoring (ABGs) Acid-base monitoring (ABGs) Monitoring depth of anesthesia Monitoring depth of anesthesia

22. Alarms Purpose: Alarms serve to alert equipment operators that some monitored variable or combination of variables is outside some region Purpose: Alarms serve to alert equipment operators that some monitored variable or combination of variables is outside some region Motivation: recognition of limited attentiveness capability in humans, even under good operating conditions Motivation: recognition of limited attentiveness capability in humans, even under good operating conditions

23. 8 Axes of Clinical Anesthesia Monitoring (A Conceptual Model) Axis I - Airway /Respiratory Axis I - Airway /Respiratory Axis II - Circulatory / Volume Axis II - Circulatory / Volume Axis III - Depth of Anesthesia Axis III - Depth of Anesthesia Axis IV - Neurological Axis IV - Neurological Axis V - Muscle Relaxation Axis V - Muscle Relaxation Axis VI - Temperature Axis VI - Temperature Axis VII - Electrolytes / Metabolic Axis VII - Electrolytes / Metabolic Axis VIII - Coagulation Axis VIII - Coagulation

24. Airway / Respiratory Axis Correct ETT placement Correct ETT placement ETT cuff pressure ETT cuff pressure Airway pressure Airway pressure Oxygenation Oxygenation Ventilation Ventilation Spirometry Spirometry Pulmonary biomechanics Pulmonary biomechanics Airway gas monitoring Airway gas monitoring Clinical: wheezing, crackles, equal air entry, color, respiratory pattern (rate, rhythm, depth, etc.) Clinical: wheezing, crackles, equal air entry, color, respiratory pattern (rate, rhythm, depth, etc.)

25. Circulatory Axis Cardiac output Cardiac output Input pressures (CVP, LAP) Input pressures (CVP, LAP) Output pressures (BP, PAP) Output pressures (BP, PAP) Pacemaker: rate, conduction Pacemaker: rate, conduction Cardiac contractility Cardiac contractility Vascular resistances (SVR, PVR) Vascular resistances (SVR, PVR) Intracardiac shunts Intracardiac shunts

26. Cardiac Monitoring Methods Symptoms and signs: eg, angina, diaphoresis, mental state Symptoms and signs: eg, angina, diaphoresis, mental state Finger on the pulse: rate, rhythm, pulse “volume” Finger on the pulse: rate, rhythm, pulse “volume” Auscultation: rate, rhythm, murmurs, extra sounds Auscultation: rate, rhythm, murmurs, extra sounds Electrocardiogram: rate, rhythm, ischemia Electrocardiogram: rate, rhythm, ischemia Pulse oximeter waveform: rate, rhythm Pulse oximeter waveform: rate, rhythm Blood pressure: cuff, oscillotonometry, art. line Blood pressure: cuff, oscillotonometry, art. line Volume Status: low-tech, high-tech Volume Status: low-tech, high-tech

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

28. CNS Monitoring Clinical: sensorium, reflexes, “wake up test” Clinical: sensorium, reflexes, “wake up test” Electroencephalography: raw EEG, compressed spectral arrays (CSA), 95% spectral edge, etc. Electroencephalography: raw EEG, compressed spectral arrays (CSA), 95% spectral edge, etc. Evoked potentials (esp. somatosensory EPs) Evoked potentials (esp. somatosensory EPs) Monitoring for venous air emboli Monitoring for venous air emboli Intracranial pressure (ICP) monitoring Intracranial pressure (ICP) monitoring Transcranial doppler studies Transcranial doppler studies (MCA flow velocity) (Research) (MCA flow velocity) (Research) Jugular bulb saturation (Research) Jugular bulb saturation (Research) Cerebral oximetry (Research) Cerebral oximetry (Research)

29. Relaxation Axis Clinical Signs +/- Nerve Stimulator Clinical Signs +/- Nerve Stimulator Mechanomyography Mechanomyography Electromyography Electromyography Piezoelectric methods Piezoelectric methods Special methods (e.g. DBS) Special methods (e.g. DBS)

30. Temperature Monitoring Rationale for use detect/prevent hypothermia detect/prevent hypothermia monitor deliberate hypothermia monitor deliberate hypothermia adjunct to diagnosing MH adjunct to diagnosing MH monitoring CPB cooling/rewarming monitoring CPB cooling/rewarmingSites Esophageal Esophageal Nasopharyngeal Nasopharyngeal Axillary Axillary Rectal Rectal Bladder Bladder

31. Electrolyte / Metabolic Axis Fluid balance Fluid balance Sugar Sugar Electrolytes Electrolytes Acid-base balance Acid-base balance Nutritional status Nutritional status

32. Coagulation Monitoring Clinical signs Clinical signs PT / PTT / INR PT / PTT / INR ACT ACT Platelet counts Platelet counts Factor assays Factor assays TEG TEG

33. The End