Patient Monitoring System (BMEg 5221)

Lecture:1
By Ahmed A.
Some equipment in mind
 • INTRODUCTION TO PMS

Patient Monitoring System:

Continuous measurement of patient parameters;
✓ Cardiac monitoring, heart rate and rhythm,
✓ Respiratory monitoring, respiratory rate
✓ Hemodynamic monitoring, blood pressure
✓ blood-oxygen saturation,
✓ Body Temperature,
✓ and many other parameters
PMS are available in two forms:
• Single-parameter monitoring system:
➢This system is used for measuring the blood pressure of
a human body, monitoring ECG, monitoring SPO2
(oxygen saturation in blood), and so on.

• Multi parameter monitoring system:

➢This system is used for monitoring multiple critical
physiological signs of patients by transmitting the vital
information like ECG, respiration rate and blood
pressure, etc..
 Application of PMS

There are at least four categories of patients who need

physiological monitoring:
➢Patients with unstable physiological regulatory systems; for
example, a patient whose Respiratory system is suppressed
by a drug overdose or anesthesia
➢Patients with a suspected life-threatening condition; for
example, a patient who has findings indicating an acute
myocardial infarction (heart attack)
➢ Patients at high risk of developing a life-threatening
condition; for example, patients Immediately after
open-heart surgery or a premature infant whose heart
and lungs are not fully developed
➢Patients in a critical physiological state; for example,
patients with multiple trauma or septic shock.
Human signals
The human body produces a wide variety of electrical and
other types of signals, which are a perfect source of
information for the medical community.
Signals can be grouped into three types:
✓ Periodic
✓ Static
✓ Random.
Periodic signals (sometimes called repetitive signals) are
symmetric and repetitive signals.
ECG, for example, has a very predictable pattern. blood
pressure waveforms and respiratory waveforms.
Periodic waveforms are commonly monitored, and their
frequency is counted (and recorded or displayed).
Static signals: are very regular and unchanging.
Temperature is a good example; it might change, but it
does so very slowly and in very small increments. These
signals often appear on a display as a straight line.

Random signals seemingly have no pattern, although

some signals (like an EEG) may have some common
characteristics. Random signals may have a common
frequency but still have an unpredictable waveform.
Electromyograms, which record the electrical activity of
muscles, also fit this type of signal
Basic Components:
➢Sensors (e.g., Electrode, probe ,pressure transducer)
captures the signal.
➢Signal Conditioners to amplify or filter the display
device (e.g., Amplifier, oscilloscope, paper recorder)
➢Computer processor to analyze data and direct report
(e.g., paper reports, storage for graphic files, summary
reports)
➢Evaluation or controlling components to regulate the
equipment or alert the nurse(e.g., a notice on the display
screen, alarm signal)
INTENSIVE CARE UNIT
 INTENSIVE CARE UNIT

A section of a hospital where special medical equipment

and services are provided for patients who are seriously
➢ Injured
➢ Ill
➢ Have undergone a major surgical procedure
An ICU may be designed and equipped in two ways
➢ to provide care to patients with a range of
conditions,
➢ to provide specialized care to patients with
specific conditions
 Cardiothoracic ICU (CTICU): Mainly cares for
postoperative cardiac and thoracic (heart and lungs) surgery
patients, providing necessary cardiopulmonary monitoring
and assistance.

Surgical ICU (SICU): cares for acutely ill patients in the

post-operative phase of major surgery.

Neurosurgical ICU: Cares for patients with acute

conditions involving the nervous system or patients who
have just had neurosurgical procedure and require
equipment for monitoring and assessing the brain and spinal
cord.
 Medical ICU (MICU): cares for critically ill patients with
medical conditions related to liver problems, kidney
problems, lung problems, blood disorders and cancers,
among other conditions.
Transplant ICU (TICU): cares for transplant patients and
donors in various stages of the transplant process, mainly
post-operative.
It is particularly designed to decrease a patient’s
susceptibility to infections after surgery.
Cardiac care unit (CCU): or Cardiopulmonary ICU
(CICU): unit that provides specialized care and monitoring
for patients with myocardial infarction, severe myocarditis,
and other life-threatening heart diseases.
 Also Pediatric CICU for pediatric patients with
congenital heart diseases and other disorders requiring
24-hour observation and care.

Pediatric ICU (PICU): unit specializing in the care of

critically ill infants, children, and teenagers
.
Neonatal ICU (NICU): unit deigned and equipped to
care for infants who are ill, born prematurely, or have a
condition requiring constant monitoring
Patient monitoring equipment includes the following:
➢ Acute care physiologic monitoring system; Comprehensive
patient monitoring systems that can be configured to
continuously measure and display a number of parameters
▪ Cardiac output
▪ Amount of oxygen and carbon dioxide in the blood
▪ ECG
▪ Respiration rate (breathing)
▪ Blood pressure body temperature. Each patient bed in
an ICU has a physiologic monitor that measure these
body activities. All monitors are networked to a central
nurses station.
➢ Pulse oximeter monitors the retrial hemoglobin saturation
(oxygen level) of the patient's blood with a sensor clipped over
the finger or toe.
•Intracranial pressure monitor: measures the pressure
of fluid in the brain in patients with head trauma or other
conditions affecting the brain (such as tumors, edema, or
hemorrhage).
These devices warn of elevated pressure and record or
display pressure trends.
Intracranial pressure monitoring may be a capability
included in a physiologic monitor.
•Apnea monitor: continuously monitors breathing via
electrodes or sensors placed on the patient.
An apnea monitor detects cessation of breathing in
infants and adults at risk of respiratory failure, displays
respiration parameters, and triggers an alarm if a certain
amount of time passes without a patient's breath being
detected.
Apnea monitoring may be a capability included in a
physiologic monitor.
Apart from equipments some more biomedical
instrumentation found in ICU’s are
•Arterial Line: the catheter
inserted into the patient’s
artery, usually in the arm, for
continuous direct measurement
of blood pressure, oxygen, and CO2 concentration in the
blood, as well as other physiological parameters. The
arterial line in then connected to the bedside monitor.

•Bedside Monitor: a monitor that is attached to the

patient, invasively or noninvasively, by several electrodes
and transducers. The most important parameter is the ECG
measurement, but blood pressure is also measured
indirectly.
•Central venous (CVP) line: a thin tube inserted into a
vein of the patient’s arm or chest to measure the venous
blood pressure. The other end of the tube is connected to
the monitor.
•Endo-tracheal tube: the tube is connected to a respirator
to help the patient in breathing. It is inserted through the
nose or mouth and then down the throat and between the
vocal chords. The patient cannot speak as long as this tube
is connected to the respirator.
•Nasogastric tubing: A tube that is passed –through the
nose and down through the nasopharynx and esophagus into
the stomach. This enables to drain gastric contents, obtain a
specimen of the gastric contents or introduce a passage into
the GI tract.
•Swan-Ganz Cather: Useful to measure right atrial,
pulmonary artery, right ventricular pressures and indirectly
measure left atrial pressures, cardiac output and systemic
vascular resistance
Neonatal ICU
 Newborn babies who need intensive medical attention
are often admitted into the Neonatal Intensive Care Unit
(NICU).
The NICU combines advanced technology and trained
healthcare professionals to provide specialized care for the
tiniest patients. NICUs may also have intermediate or
continuing care areas for babies who are not as sick, but do
need specialized nursing care.
About 10% of all newborn babies require care in a
NICU.
The patient sizes may range from extremely small
premature newborns (600 grams), up to babies that are a
few months old (ie.6 months old= 8 Kilograms)
 Monitoring in the NICU

In some hospitals, all babies admitted into the NICU

are monitored with ECG electrodes;
in some others, they use the infrared monitor on the
extremities for measuring oxygen saturation in the blood
and heart rate, using ECG electrodes only in the most
critical situations.
 Incubator

When a baby is relatively stable but still premature,

requiring intravenous fluids or other special attention, he
or she is cared for in an "incubator." The incubator keeps
the baby warm with moistened air in a clean environment,
and helps to protect the baby from noise, drafts, infection,
and excess handling. Temperatures range around 30 to
37ºC, humidity levels range from 50 to 90%, depending
on the baby’s size and age.
Phototherapy lamps

Phototherapy lights are used when babies are jaundiced

(yellow). Some degree of jaundice, which is caused by the
presence of a molecule called bilirubin in the blood, is
common and even normal in newborns. However, in sick
infants, jaundice can result from a variety of problems, and
when jaundice is extreme it can cause brain damage.
Certain wavelengths of light (in the blue part of the
spectrum) can cause a chemical reaction that converts
bilirubin into a harmless form as blood passes through the
skin.
 List of Equipment that must be available in the
NICU are:
✓Heart or cardiorespiratory monitor
✓Blood pressure monitor
✓Temperature
✓Pulse oximeter
✓Transcutaneous oxygen/carbon dioxide monitor
✓Respirator or mechanical ventilator
✓Continuous positive airway pressure (CPAP)
✓Extracorporeal membrane oxygenation (ECMO)
✓Endotracheal tube (ET)
✓Respirator or mechanical ventilator
 Coronary care unit
(CCU)

CCU is usually configured differently than a typical hospital

ward.
• The Coronary Care Unit is funded for 9 beds for acute
cardiology patients and two beds allocated to the Chest Pain
Assessment Unit. The unit also has capacity to increase the
number of beds to 14 in times of increased demand for beds.
potentially life-threatening cardiac conditions
including:
✓ acute congestive heart failure
✓ acute coronary syndromes
✓ cardiac arrhythmias
✓ patients pre/post intervention cardiac procedures

List of Equipment that must be available in the CCU are

✓ Monitor ✓ Ventilator
✓ Blood Gas Analyzer ✓ Nebulizer
✓ Central Station ✓ ECG
✓ Syringe Infusion Pump ✓ Suction Machines
✓ Defibrillator ✓ Mobile Light
✓ External Pacemaker
 CARDIAC MONITOR:

The cardiac monitor is a

device that shows the electrical
and pressure waveforms of the
cardiovascular system for
measurement and treatment. It
allows the detection of changes in
heart rate, rhythm and conduction,
and is essential in the detection of
life threatening arrhythmias.
• Continuous cardiac monitoring is an
important tool in the clinical
assessment of patients with a variety
of conditions. This is achieved using
a cardiac monitor, connected to a
cable lead and skin electrodes, which
captures the electrical activity
predominantly through a single view
• The monitor function includes:
✓ A display of heart rate and rhythm
✓ Sound alarms above or below pre-
set limits
✓ The provision of rhythm strips to
document evidence of arrythmia
 Basic Cardiac Monitoring
Electrocardiogram (ECG)
1. Graphic record of heart’s electrical activity
2. Body acts a conductor of electricity and the heart is the
largest generator of electrical energy
3. Electrodes placed on the skin can detect total electrical
activity within the heart
4. Electrical impulses on the skin surface have very low
voltage. The ECG machine amplifies these impulses and
records them on the ECG graph paper or on a monitor
screen called an oscilloscope.
5. Positive impulses appear as "upward" deflections on the
graph paper or monitor screen
6. Negative impulses appear as "downward" deflection
on the graph paper or monitor screen
7. Absence of any electrical impulse produces an
isoelectric or "flat" line
8. "Artifacts" are deflections the ECG produced by
factors other than the electrical activity of the heart.
Common causes are
(a) Muscle tremors
(b) Shivering
(c) Patient movement
(d) Loose electrodes
(e) 60 cycle interference
(f) Machine malfunction
(9) Eliminate all artifacts before attempting to record
an ECG

(a) Replace loose electrodes

(b) Cover patient with a blanket to prevent shivering
(c) Wipe oily skin or diaphoretic skin with alcohol and
then attach leads to increase adherence to the skin
 Preparation
Cardiac monitor is most commonly
used to monitor electrical activity of the
heart, the patient can expect the
following preparations.
✓ The sites selected for electrode
placement on the skin will be
shaved and cleaned causing surface
abrasion for better contact between
the skin and electrode.
✓ The electrode will have a layer of
gel protected by a film, which is
removed prior to placing the
electrode to the skin.
✓ Electrode patches will be placed
near or on the right arm, right leg,
left arm, left leg, and the center left
side of the chest.
✓ The cable will be connected to the
electrode patches for the
measurement of a five-lead
electrocardiogram. Additional
configurations are referred to as
three-lead and 12-lead
electrocardiograms.
ECG Waveforms
Criteria for Proper Measurement

Factors affecting accurate measurement of ECG are:

1. Proper placement of electrodes. In order to record the
strongest signals from the appropriate angles,
electrodes must be placed precisely. Failure to do so
may result in erroneous readings.

2. Good skin contact. Because ECG signals are small, low

voltages (millivolts), the electrodes must make good
contact with the patient’s skin in order to get an
accurate reading. Good contact requires proper skin
preparation and periodic electrode replacement.
4. Proper selection of leads. Leads must be selected
with the correct cable sets to measure the
appropriate electrical activity. Selecting the wrong
leads could result in misdiagnosis of the heart’s
condition.
5. Elimination of external interference. A patient’s
movements or bones can interfere with the signal,
as can pacemaker activity and electrical
interference from electrosurgical units (ESU). In
the OR application, for example, electrodes should
be placed equidistant from the surgical site to
improve the ESU suppression. Other extraneous
sources of electrical interference can be electrical
appliances around the patient.
Bed Side Monitor:
A bedside monitor is a display of the pertinent
measurements of the patient’s body functions on a TV
screen or on a computer monitor.
Some of the standard measurements are ECG,
respiration, noninvasive blood pressure, pulse
oximetery, and arrhythmia analysis.
However, some monitors have universal ports for
displaying other measurements, such as invasive blood
pressure, cardiac output temperature, and CO2 (end
tidal carbon dioxide) in addition to the standard
measurement displayed.
 The wires or leads of the bedside monitor are
connected to sensing devices that are attached to the
patient’s body. The sensing devices send electronic signals
to the monitor for display.
Some of the typical values of bedside monitoring
measurements are as follows
Sl no Physiological parameter Adults Neonates
1 Blood Pressure 120/80 mmHg -----
2 Heart rate 50-90 bpm (beats) 120-180 bpm
3 Respiratory rate 12 bpm (breaths) 40-80 bpm
4 Temperature 370C 370C
5 SPO2 95-100 % 95-98%
6 Cardiac Output 6 L/min -----
O2 17 % O2 17 %
7 Expired Gases N 79 % N 79 %
CO2 4% CO2 4%
bedside
monitor
 CENTRAL MONITORS
Receivers are connected to a bedside monitor and/or
central station monitor. Some central station monitors
can be networked so that a patient’s waveform can be
simultaneously displayed at multiple locations within a
hospital.
Some telemetry systems allow receivers to be
connected to a bedside monitor or to be used on the same
central station network as hardwired bedside monitors.
This allows the clinician to view a patient’s ECG and
other monitored information at the bedside and at the
central station.
 Patient safety

The effects of electrical currents on the human body and

tissue may range from a tingling sensation to tissue burns
and heart fibrillation leading to death.

Electrical energy has three general effects on the body:

✓ Resistive heating of tissue

✓ Electrical stimulation of the tissue (nerve and muscle)
✓ Electrochemical burns (for direct current)
HUMAN DETECTION OF CURRENT
Threshold Current (1–5 mA): This is the level of current
required to perceive the feeling of current. A slight fuzzy
feeling or tingling sensation is common at this current
strength.
Pain Current (5–8 mA): This current level will produce a
pain response, which may feel like a sharp bite.

Let Go Current (8–20 mA): This current level results in

involuntary muscle contraction. Nerves and muscles are
strongly stimulated, resulting in pain and fatigue. At the
low end of let go current is the maximum amount of
current from which a person can move away voluntarily
(about 9.5mA). At these levels, injuries may result from
the instinct to pull away, for example, arm dislocation or
broken bones from falls.
Paralysis Current (>20 mA): At levels greater than about
20 mA, the muscles lose their ability to relax. This
includes the muscles involved in breathing. The breathing
pattern can no longer be maintained and results in
respiratory paralysis. Respiratory paralysis can result in
death.

Fibrillation (80–1,000 mA): At levels between 80 and

1,000mA, the heart goes into fibrillation. Fibrillation is the
unsynchronized contraction of the muscle cells within the
heart. During fibrillation, the heart is ineffective in
pumping blood to the body. Heart fibrillation will result in
death.
Defibrillation (1,000–10,000 mA): The delivery of
electrical energy to the fibrillating heart is called
defibrillation. A large current delivered by paddles at the
skin, through muscle and bone, can resynchronize all of
the cardiac muscles. Then, coordinated electrical
generation can return to the heart. During open-heart
surgery, spoon-shaped paddles can deliver much lower
currents directly to the heart to induce fibrillation (to
perform bypass surgery, for example) and then defibrillate
the heart after the procedure is complete.
Biomedical variable Description

ECG Electrocardiogram
EEG Electroencephalogram
HR Heart rate (beats per minute)
CO Cardiac output (liter per minute)
pH H+ concentration in blood plasma
paO2 Oxygen partial pressure in blood plasma
paCO2 Carbon dioxide partial pressure in blood plasma
SaO2 Percentage of hemoglobin cells O2 saturated
ETCO2 End tidal CO2
NIBP Noninvasive blood pressure
BP Invasive blood pressure
AA Concentration of inspired anesthetic agent
N2O Concentration of inhaled nitrous oxide
Respiratory rate Number of inspirations and expirations per minute
EMG Electromyogram
EP Evoked potentials
Temperature Invasive or noninvasive body temperature
THE END