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1、Monitoring in Anesthesia,Topic module,1.2.3.(NIBP,SpO2,ECG,ET-CO2),Contents,IntroductionWhat is monitoring?Which,Why and How to monitor?Level of monitoringStandards for basic intraoperative monitoring(ASA)Systematic monitoringConclusion,Monitoring:A Definition,.interpret available clinical data to h
2、elp 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),What is monitoring?,to monere(,)Physiologic parameter&Patient safety parameter Clinical skills&Monitoring equ
3、ipment Data collection,interpretation,evaluation,decisionProblem seeking,Severity assessment,Therapeutic assessment,Evaluation of Anesthetic interventions,Patient Monitoring and Management,Involves Things you measure(physiological measurement,such as BP or HR)Things you observe(e.g.observation of pu
4、pils)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),Level of monitoring,Routine/Speciali
5、ze/ExtensiveNon-equipment/Non-invasive/Minimally invasive/Penetrating/Invasive/Highly invasiveSystematicRespiratory/Cardiovascular/Temperature/FetalNeurological/Neuro-muscular/Volume status&RenalStandards for basic intraoperative monitoring(ASA),Standards for basic intraoperative monitoring(ASA:Amer
6、ican Society of Anesthesiologists),Standard I Qualified anesthesia personnel shall be present in the room throughout the conduct of all GA,RA,MACStandard II During all anesthetics,the patients respiratory(ventilation,oxygenation),circulation and temperature shall be continually evaluated,Monitoring
7、in the Past,Visual monitoring of respiration and overall clinical appearanceFinger on pulseBlood pressure(sometimes),Monitoring in the Past,Finger on the pulse,Harvey Cushing Not just a famous neurosurgeon but the father of anesthesia monitoring,Invented and popularized the anesthetic chartRecorded
8、both BP and HREmphasized the relationship between vital signs and neurosurgical events(increased intracranial pressure leads to hypertension and bradycardia),Examples of Multiparameter Patient Monitors,Some Specialized Patient Monitors,Depth of Anesthesia Monitor,Evoked Potential Monitor,Transesopha
9、geal Echocardiography,Cardiovascular monitoring,Routine monitoringCardiac activityNon-invasive blood pressure(NIBP)Electrocardiography(ECG)Advanced monitoringDirect arterial blood pressureCardiac filling pressure monitorCentral venous pressurePulmonary capillary wedge pressure,Cardiovascular monitor
10、ing,ElectrocardiographyCardiac activityArrhythmia:Lead IIMyocardial ischemia:ECG criteriaElectrolyte imbalancePacemaker function,Cardiovascular monitoring,ECG 1.lead II,modified V5 2.-arrhythmia:bradycardia,tachycardia,AF,PVC,VT,VF-Myocardial ischemia-electrolyte imbalance,Cardiovascular monitoring,
11、Non-invasive blood pressure(NIBP)Cuff:width 120-150%limb diameter,air bladder includes more than halfway around limbManometer:aneroid,mercuryDetector:manual,automated,Cardiovascular monitoring,Non-invasive blood pressureInaccurate:cuff size,inflated pressure,shivering,cardiac arrhythmia,severe vasoc
12、onstriction,Proper application,Narrow cuff,Loose cuff,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 arter
13、ial blood sampling:ABG,Acid-base/electrolyte/glucose disturbance,Coagulopathies,Cardiovascular monitoring,Direct arterial pressure monitorContraindicationsLocal infectionImpaired blood circulation:Raynauds phenomenon,DMRisks of thrombosis:hyperlipidemia,previous brachial artery cannulationModified A
14、llens test?(),Cardiovascular monitoring,Direct arterial pressure monitor Complications Direct trauma:AV-fistula,Aneurysm Hematoma Infections Thrombosis Embolization Massive blood loss,Cardiovascular monitoring,Cardiac filling pressure monitor Frank-Starling curve:optimum Preload maximize ventricular
15、 performance(Stroke volume,CO.)Preload=Myocardial fiber length(2.2 micron)LV Preload LVEDV LVEDP LAP PCWP PAP RVP RAP CVPMyocardium function,LV compliance,Mitral valve,Airway pressure,Pulmonary vascular resistance,Pulmonic valve,Tricuspid valve,Cardiovascular monitoring,Cardiac filling pressure moni
16、torLV Preload LVEDV LVEDP LAP PCWP PAP LVEDP RVEDP RAP CVP,Cardiovascular monitoring,Cardiac filling pressure monitorPCWP:Pulmonary capillary wedge pressureCVP:Central venous pressure,Cardiovascular monitoring,PCWP:Pulmonary capillary wedge pressureCVP:Central venous pressureFluid Challenge test to
17、optimize preload and maximize Cardiac performance,Respiratory monitoring,Ventilatory monitoringOxygenation monitoringMachine and Circuit monitoringClinical skillsMonitoring devices,Ventilatory monitoring,Clinical skillsDirect observation:rate,rhythm,volume of respirationAuscultation:precordial,esoph
18、ageal stethoscopePalpation:reservoir bag movementMonitoring devicesSpirometerAirway pressure manometerCircuit disconnection alarm,Ventilatory monitoring,Capnometer(End-tidal CO2 analysis)relationship with PaCO2:ETCO2 PaCO2 3-6 mmHgmainly depends on dead space ventilationnormal value 30 35 mmHgInfrar
19、ed absorption spectrographyMain-stream VS.Side-stream,Ventilatory monitoring,Capnogram:normal curve1.Dead space air(no CO2)2.Mixed bronchus&alveolus air(CO2 upstroke)3.Alveolus air(CO2 plateau),Inspiration,ETCO2,1,2,3,Ventilatory monitoring,Capnometer(End-tidal CO2 analysis)Most useful in detection
20、of Esophageal intubation,airway or circuit disconnectionUseful in CO2 rebreathing,partial recovery of neuro-muscular blockade,good predictor of successful CPR,(waveform of ET-CO2),Capnograph-esophageal intubation-bronchial intubation-airway obstruction-circuit disconnect-circuit leakage-partial rebr
21、eathing-spontaneous breathing(recovary of neuromuscular blockade)-hypoventilation,Oxygenation monitoring,Clinical skillsDirect observation:impaired mental function,sympathetic overactivities,appearance(+cyanosis)Auscultation:wheezing,crepitationMonitoring devicesArterial blood gas analysisPercutaneo
22、us O2 measurementPulse oximeter,Oxygenation monitoring,Pulse oximeterPercent of oxyhemoglobin/total hemoglobinOxyhemoglobin absorp 940 nm.Deoxyhemoglobin absorp 660 nm.Caution:SpO2 PaO2,Oxygenation monitoring,Pulse oximeterSpO2 correlates with PaO2 as in Oxygen-hemoglobin dissociation curveSpO2 90 P
23、aO2 60 mmHg(moderate hypoxemia)75 40 mmHg(mixed venous oxygen sat.)50 27 mmHg(P50),Oxygenation monitoring,Pulse oximeter artifactsAbnormal hemoglobin:COHb,MetHb,HbFDye:Methylene blueAnemiaAmbient lightArterial saturationBlood flowMotionNail polishElectro-cautery,Wave form Pulse oximeter Pulse oximet
24、er artifacts Cause of Rt-Lt shift of oxygen-hemoglobin dissociation curve,Machine&circuit monitoring,Safety systemDISS,PISS,Quick disconnection adaptorOxygen fail-safe valve,Oxygen supply failure alarmOxygen analyzerAirway gas compositionClinical skills:flowmeters,vaporizersMonitoring devices:Infrar
25、ed spectrometer,Depth of Anesthesia,Clinical Signseye signsrespiratory signscardiovascular signsCNS signsEEG monitoringFacial EMG monitoring(experimental)Esophageal contractility(obsolete),Neurologic monitoring,Depth of anesthesia(BIS)EEGEvoked potentialsCerebral blood flowIntracranial pressure,Neur
26、omuscular monitoring,Clinical skillsMonitoring device:PERIPHERAL NERVE STIMULATOR,Volume status and renal monitoring,Estimate blood lossUrine outputHemodynamic stability,Volume status and renal monitoring,Estimate blood lossUrine outputHemodynamic stability,Electrolyte/Metabolic monitoring,Fluid bal
27、anceSugarElectrolytesAcid-base balance,Coagulation Monitoring,PT/PTT/INRACTPlatelet countsFactor assays TEGClinical sign,Temperature monitoring,4 mechanism of heat lossPerioperative hypothermia(BT36)Core temperature:nasopharynx,esophageal,tympanic membrane,pulmonary a.catheter,bladder,rectum,Tempera
28、ture Monitoring,Rationale for usedetect/prevent hypothermiamonitor deliberate hypothermia adjunct to diagnosing MHmonitoring CPB cooling/rewarming,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,Conclusion out NIBP,ECG,ET-CO2,SpO2,
