MONITORING IN ICU AND

ANESHTESIOLOGY

2016
VSMU
Content
Standards for basic anesthetic monitoring.........................................................................................2
Noninvasive arterial blood pressure monitoring................................................................................3
Invasive pressure monitoring.............................................................................................................4
Electronic transducer.....................................................................................................................5
Factors affecting errors in invasive monitoring..............................................................................6
Arterial pressure. Arterial pressure waveform...............................................................................6
Arterial line placement...................................................................................................................8
Electrocardiography...........................................................................................................................9
Central venous catheterization........................................................................................................11
Techniques & Complications........................................................................................................11
Capnography....................................................................................................................................13
Indications & Contraindications...................................................................................................13
Techniques & Complications........................................................................................................13
Temperature....................................................................................................................................14
Urinary output..................................................................................................................................15
Peripheral nerve stimulation............................................................................................................16
 Clearly, one of the most important roles is serving as the ever-vigilant set of “eyes” to
ensure patient safety. Despite the introduction of new methods to monitor the anesthetized
patient, hemodynamic monitoring and the analysis of these well-known parameters remain
central to assessing patient wellbeing.

Standards for basic anesthetic monitoring

In an effort to ensure patient safety, the American Society of Anesthesiologists (ASA)
has created “Standards for Basic Anesthetic Monitoring” (approved by the ASA House of
Delegates on October 21, 1986 and last affirmed on October 25, 2005). In general:
These standards apply to all anesthesia care although, in emergency circumstances,
appropriate life support measures take precedence. These standards may be exceeded at
any time based on the judgment of the responsible anesthesiologist. They are intended to
encourage quality patient care, but observing them cannot guarantee any specific patient
outcome. They are subject to revision from time to time, as warranted by the evolution of
technology and practice. They apply to all general anesthetics, regional anesthetics, and
monitored anesthesia care. This set of standards addresses only the issue of basic anesthetic
monitoring, which is one component of anesthesia care. In certain rare or unusual
circumstances 1) some of these methods of monitoring may be clinically impractical and 2)
appropriate use of the described monitoring methods may fail to detect untoward clinical
developments. Brief interruptions of continual (prolonged without any interruption at any
time) monitoring may be unavoidable. These standards are not intended for application to
the care of the obstetrical patient in labor or in the conduct of pain management.
STANDARD I states, “Qualified anesthesia personnel shall be present in the room
throughout the conduct of all general anesthetics, regional anesthetics and monitored
anesthesia care.”
STANDARD II states, “During all anesthetics, the patient’s oxygenation, ventilation,
circulation and temperature shall be continually evaluated.” Standard II includes specific
recommendations with regard to hemodynamic evaluation. Specifically, Standard II aims to
“ensure the adequacy of the patient’s circulatory function during all anesthetics”:
1. Every patient receiving anesthesia shall have the electrocardiogram continuously
displayed from the beginning of anesthesia until preparing to leave the anesthetizing
location.
2. Every patient receiving anesthesia shall have arterial blood pressure and heart rate
determined and evaluated at least every five minutes.
3. Every patient receiving general anesthesia shall have, in addition to the above, circulatory
function continually evaluated by at least one of the following: palpation of a pulse,
auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound
peripheral pulse monitoring, or pulse plethysmography or oximetry.
The need for real-time invasive hemodynamic data versus noninvasive assessment of
cardiovascular function is determined by several factors, including the ASA physical status,
type of surgery, anticipated blood loss, and likelihood for hemodynamic instability during
surgery. The ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care
for noncardiac surgery can be used as a risk assessment tool.
 Hemodynamic monitoring is an essential part of every anesthetic and includes
directly or indirectly monitoring pressure, flow, and resistance in the arterial and venous
systems of every patient. The ASA standards of basic anesthetic monitoring require
assessment of adequate circulatory function during all anesthetics, including measurement
of arterial blood pressure (ABP) and heart rate at least every 5 minutes and continuously
monitoring the electrocardiogram (ECG). Other clinical signs, such as skin and mucosal color,
palpation of a peripheral pulse, and auscultation of heart sounds, may aid in the assessment
of the cardiovascular system. An adequate signal from a pulse oximeter or the presence of
expired CO2on capnography may be a gross indicator of circulation. The need for real-time
invasive hemodynamic data versus continual noninvasive assessment of cardiovascular
function is determined by the acuity of the patient, type of surgery, and physiologic reserve
of the patient.

Noninvasive arterial blood pressure monitoring

Noninvasive arterial blood pressure (NIBP) monitoring may involve direct palpation,
use of a Doppler probe, auscultation, arterial tonometry, or more commonly, oscillometry.
Several methods of NIBP estimation are described in Fig 1. Automated NIBP machines
frequently use the oscillometric method. Blood pressure cuff oscillations are sensed by a
transducer. The lowest cuff pressure with the greatest average oscillation amplitude is
sensed as the mean arterial pressure (MAP). Systolic and diastolic blood pressures are
determined by identifying the cuff pressures where the amplitudes of oscillations are specific
ratios of the maximum oscillation amplitude. Here are some important points to consider:
 Cuff width influences the accuracy of blood pressure measurements. A narrow cuff
may overestimate blood pressure, whereas a wide cuff may underestimate the
pressure. This is because the pressure necessary to occlude the artery is greater with
a narrow cuff and less with a wide one. Importantly, a narrow cuff more greatly over
estimates the systolic blood pressure than a wide cuff underestimates the systolic
blood pressure.
 Patient movement during oscillometric measurement, including shivering, may cause
artifact and can result in inaccurate measurement.
 Counter-intuitively, more peripheral arterial measurements result in an exaggeration
of the systolic and pulse pressures as the result of changes in the waveform
morphology. For example, the dorsalis pedis artery pressure reading may be higher
than the aortic root pressure. It should also be noted that changes in vascular
resistance, such as from hypothermic cardiopulmonary bypass and vasodilating
drugs, can further affect relative differences in pressure measurements recorded
from site to site.
 Korotkoff described five sounds heard when taking blood pressure measurements
with the auscultatory method. Typically, systolic blood pressure is measured as the
pressure at which the first Korotkoff sound is first heard, whereas diastolic blood
pressure measured as the pressure at which the fourth Korotkoff sound is just
audible. Interestingly, the mechanism by which Korotkoff sounds are generated has
not been well understood and many theories exist.
  The auscultatory gap is the period during which sounds indicating true systolic
pressure fade away and reappear at a lower pressure point. Failure to recognize this
gap can result in not identifying hypertensive patients.

Figure 1. Methods for NIBP measurement

Complications of NIBP monitoring:

 Bruising and petechiae formation

 Neuropathy
 Measurement errors
 Limb ischemia

Invasive pressure monitoring

Principles of invasive pressure monitoring. Placing a hollow cannula in a vessel of the
cardiovascular system connecting to calibrated transducers with a fluid-filled high-pressure
tubing system allows for accurate invasive pressure measurements. Cannulas may be placed
in virtually any portion of the cardiovascular system. Commonly, they are placed in central or
peripheral arteries for arterial pressure, the superior vena cava or right atrium for central
venous pressure (CVP), and the pulmonary artery for pulmonary artery pressure and
pulmonary artery wedge pressure (PAWP). Checklist for invasive monitoring:

 Intravascular cannula (arterial line/CVC/PAC)

 Infusion and tubing
 Transducer
 Display screen
 Mechanism for zeroing and calibration

Electronic transducer
The cannula is connected to high-pressure tubing that is filled with saline. This acts as
a continuous column of fluid that transmits intraluminal pressure changes to the transducer
diaphragm that oscillates in response to the pressure waveform. The movement is converted
to an electrical signal by a transducer. The transducer accomplishes this by acting as part of a
capacitor, inductor, or, most commonly, a strain gauge. The strain gauge uses variable
resistors, the electrical resistance of which increases with increasing length. The diaphragm
of the transducer moves a small plate connected to four strain gauges. With any one
movement, two gauges are compressed and the other two stretched. All four strain gauges
form part of a Wheatstone bridge, increasing the sensitivity.
Calibration
Calibration is the process of validating a measurement technique or equipment. It
was an important consideration for older electronic transducers. The standard calibration is
a 50-microvolt change in potential per 10 mm Hg. Modern systems typically do not require
external calibration because they are manufactured in a standardized manner to tight
standards.
Zeroing
Zeroing removes the effect of atmospheric pressure on transmural pressure of the
tubing system by exposing the transducer system to ambient atmospheric pressure. Zeroing
is performed by opening the transducer to atmospheric pressure and electronically setting
this atmospheric pressure to zero. Occasionally, this zero baseline may drift and should be
checked frequently, because even a 5 mm Hg drift can represent a significant difference in
low-pressure systems such as CVP.
Leveling
Leveling refers to the placement of an already zeroed transducer at a particular
height where the pressures are sought to be measured (a reference point). The electrical
transducer needs to be aligned to the superior aspect of the right atrium to measure the
pressure at the level of the heart. This eliminates errors of measurement that might occur
from the hydrostatic pressure exerted by the column of blood above or below the point of
reference to be measured. A 10 cm change in height will increase or decrease the pressure
reading by 7.5 mm Hg.

To standardize measurements, the position of the right atrium is assumed to be along

the mid axillary line. For intracranial procedures, in which the pressure in the circle of Willis
is important, the transducer may be leveled to the tragus. Invasive blood pressure
monitoring devices measure blood pressure at the level of transducer and are not affected
by level of the insertion point in the extremity as long as the transducer is maintained level
to the heart. NIBP measurement devices measure pressure at the level of peripheral artery.
Therefore, if the NIBP measurements are made above or below the level of heart, then a
correction for hydrostatic pressure should be made before extrapolating the pressure at the
level of heart.

Factors affecting errors in invasive monitoring

1. Zeroing error

2. Leveling error

3. Simultaneous infusion of fluids and drugs

 Rapid administration of fluid in the CVP catheter will alter measurements

4. Variation with respiration

 Variations occur in all pressure measurements with spontaneous and positive

pressure ventilation
 Considerable variations may occur in CVP and pulmonary artery pressures during
both spontaneous ventilation and positive pressure ventilation
 Variations may be the result of changes in intrapleural pressure during the
respiratory cycle
 All CVP/pulmonary artery measurements should be performed at end expiration,
when intrapleural pressure is zero
 Arterial pressure waveform variation with respiration may be suggestive of
hypovolemia or other conditions, such as cardiac tamponade

5. Excessive positive end-expiratory pressure (PEEP)

 Measured CVP is the intraluminal pressure

 True filling pressure is the transmural pressure in the right atrium, which is equal to
the right atrial pressure (RAP) minus the sum of intrathoracic pressure and
intrapericardial pressure As transmural pressure varies throughout the ventilatory
cycle, there is a corresponding variation in venous return
 Application of PEEP increases intrathoracic pressure throughout the respiratory cycle
 Compliant lungs tend to transmit this pressure to the right atrium and impede
venous return

Arterial pressure. Arterial pressure waveform

The systemic arterial blood pressure (ABP) waveform is generated when the blood is
ejected from the left ventricle into the aorta during systole, followed by peripheral arterial
run off of this stroke volume during diastole(Fig. 2 and Fig. 3). The morphology of ABP
waveform changes as the wave travels from the aorta to the periphery. Compared with
aortic pressures, peripheral arterial waveforms have a higher systolic pressure, a lower
diastolic pressure, and thus a wider pulse pressure. The pulse arrives at the peripheral site
after some delay, and this is seen in the waveform display. Pressure wave reflection off the
tapering arterial tree is the predominant factor that influences the shape of the arterial
blood pressure waveform. Patients with reduced arterial compliance (e.g., atherosclerosis,
advancing age) have an increased pulse pressure, late systolic pressure peak, and
disappearance of the diastolic pressure wave (Fig. 4), which is the result of an early return of
the reflected pressure wave.

Figure 2. T The systolic components following the R wave on ECG consist of (1) steep pressure upstroke, peak; (2) systolic
peak pressure; and (3) decline, which correspond to the period of left ventricular systole. The down-slope is interrupted by
the (4) dicrotic notch, which reflects aortic valve closure at end systole. The remaining decay of waveform, (5) diastolic
runoff, occurs during diastole following the ECG T wave and reaches its nadir at end diastole, (6) end-diastolic pressure.
(Modified from Mark JB.Atlas of Cardiovascular Monitoring.)
Figure 3. Systolic (S) and diastolic (D) pressures are shown with arrows. Mean arterial pressure (MAP) is represented by the
area beneath the arterial pressure curve divided by the beat period, and it incorporates the S and D portions of the cardiac
cycle. (Modified from Mark JB.Atlas of Cardiovascular Monitoring.)

Indications for invasive arterial pressure monitoring include the following:

1. The need for real-time blood pressure monitoring
2. The need for repeated arterial blood gas sampling
3. Unreliable noninvasive blood pressure; for example, during cardiopulmonary bypass,
severe shock, extreme peripheral vasoconstriction, arrhythmias, severe burns, morbid
obesity, or patients with an LVAD
4. Dynamic monitoring of fluid resuscitation: systolic pressure variation, mean pressure
variation, or pulse pressure variation may be used as an indicator of volume status

Arterial line placement

The most common site for arterial line cannulation is the radial artery, given its
superficial location and the presence of good collateral circulation. Other sites include the
femoral, axillary, brachial, ulnar, dorsalis pedis, and posterior tibial arteries The Allen’s test is
used to demonstrate collateral circulation in a hand prior to cannulating the radial artery.
After elevating the patient’s hand and having the patient make a fist for 30 seconds,
pressure is applied over the ulnar and radial arteries to occlude them. The hand is opened
and ulnar pressure is released. If color does not return or returns after 7–10 seconds, then
the ulnar arterial supply to the hand is considered not sufficient and the radial artery cannot
be safely cannulated. Utility of the test, however, is questionable as there are case reports of
ischemic complications despite a normal Allen’s test. Specifics of the surgery and the
patient’s characteristics often influence the site and side of arterial cannulation. Several
techniques of insertion of the arterial line are used, including direct arterial puncture, the
Seldinger technique, and the transfixion–withdrawal technique. Ultrasound guidance can be
of value in arterial line placement.
Figure 4. Complications of arterial catheterization

Electrocardiography
All patients should have intraoperative monitoring of their electrocardiogram (ECG).
There are no contraindications.
Lead selection determines the diagnostic sensitivity of the ECG. ECG leads are
positioned on the chest and extremities to provide different perspectives of the electrical
potentials generated by the heart. At the end of diastole, the atria contract, which provides
the atrial contribution to CO, generating the “P” wave. Following atrial contraction, the
ventricle is loaded awaiting systole. The QRS complex begins the electrical activity of systole
following the 120–200 msec atrioventricular (AV) nodal delay. Depolarization of the ventricle
proceeds from the AV node through the interventricular system via the His–Purkinje fibers.
The normal QRS lasts approximately 120 msec, which can be prolonged in patients with
cardiomyopathies and heart failure. The T wave represents repolarization as the heart
prepares to contract again. Prolongation of the QT interval secondary to electrolyte
imbalances or drug effects can potentially lead to life-threatening arrhythmias (les torsade
de pointes). The electrical axis of lead II is approximately 60° from the right arm to the left
leg, which is parallel to the electrical axis of the atria, resulting in the largest P-wave voltages
of any surface lead. This orientation enhances the diagnosis of arrhythmias and the
detection of inferior wall ischemia. Lead V5 lies over the fifth intercostal space at the
anterior axillary line; this position is a good compromise for detecting anterior and lateral
wall ischemia. A true V5 lead is possible only on operating room ECGs with at least five lead
wires, but a modified V5 can be monitored by rearranging the standard three-limb lead
placement. Ideally, because each lead provides unique information, leads II and V5 should be
monitored simultaneously. If only a single-channel machine is available, the preferred lead
for monitoring depends on the location of any prior infarction or ischemia. Esophageal leads
are even better than lead II for arrhythmia diagnosis, but have not yet gained general
acceptance in the operating room. Electrodes are placed on the patient’s body to monitor
the ECG. Conductive gel lowers the skin’s electrical resistance, which can be further
decreased by cleansing the site with alcohol. Needle electrodes are used only if the disks are
unsuitable (eg, with an extensively burned patient).
Figure 5. Rearranged three-limb lead placement. Anterior and lateral ischemia can be detected by placing the left arm lead
(LA) at the V5 position. When lead I is selected on the monitor, a modified V5 lead (CS5) is displayed. Lead II allows
detection of arrhythmias and inferior wall ischemia. RA, right arm; LL, left leg

The ECG is a recording of the electrical potentials generated by myocardial cells. Its
routine use allows arrhythmias, myocardial ischemia, conduction abnormalities, pacemaker
malfunction, and electrolyte disturbances to be detected. Because of the small voltage
potentials being measured, artifacts remain a major problem. Patient or lead-wire
movement, use of electrocautery, 60-cycle interference from nearby alternating current
devices, and faulty electrodes can simulate arrhythmias. Monitoring filters incorporated into
the amplifier to reduce “motion” artifacts will lead to distortion of the ST segment and may
impede the diagnosis of ischemia. Digital readouts of the heart rate (HR) may be misleading
because of monitor misinterpretation of artifacts or large T waves—often seen in pediatric
patients—as QRS complexes. Depending on equipment availability, a preinduction rhythm
strip can be printed or frozen on the monitor’s screen to compare with intraoperative
tracings. To interpret ST-segment changes properly, the ECG must be standardized so that a
1-mV signal results in a deflection of 10 mm on a standard strip monitor. Newer units
continuously analyze ST segments for early detection of myocardial ischemia. Automated ST-
segment analysis increases the sensitivity of ischemia detection, does not require additional
physician skill or vigilance, and may help diagnose intraoperative myocardial ischemia.
Commonly accepted criteria for diagnosing myocardial ischemia require that the ECG be
recorded in “diagnostic mode” and include a flat or down sloping ST-segment depression
exceeding 1 mm, 80 msec after the J point (the end of the QRS complex), particularly in
conjunction with T-wave inversion. ST-segment elevation with peaked T waves can also
represent ischemia. Wolff–Parkinson–White syndrome, bundle-branch blocks, extrinsic
pacemaker capture, and digoxin therapy may preclude the use of ST-segment information.
The audible beep associated with each QRS complex should be loud enough to detect rate
and rhythm changes when the anesthesiologist’s visual attention is directed elsewhere.
Some ECGs are capable of storing aberrant QRS complexes for further analysis, and some
can even interpret and diagnose arrhythmias. The interference caused by electrocautery
units, however, has limited the usefulness of automated arrhythmia analysis in the operating
room.

Central venous catheterization

Indications. Central venous catheterization is indicated for monitoring central venous
pressure (CVP), administration of fluid to treat hypovolemia and shock, infusion of caustic
drugs and total parenteral nutrition, aspiration of air emboli, insertion of transcutaneous
pacing leads, and gaining venous access in patients with poor peripheral veins. With
specialized catheters, central venous catheterization can be used for continuous monitoring
of central venous oxygen saturation.
Contraindications. Relative contraindications include tumors, clots, or tricuspid valve
vegetations that could be dislodged or embolized during cannulation. Other
contraindications relate to the cannulation site. For example, subclavian vein cannulation is
relatively contraindicated in patients who are receiving anticoagulants (due to the inability
to provide direct compression in the event of an accidental arterial puncture). Some
clinicians avoid central venous cannulation on the side of a previous carotid endarterectomy
due to concerns about the possibility of unintentional carotid artery puncture. The presence
of other central catheters or pacemaker leads may reduce the number of sites available for
central line placement.

Techniques & Complications

Central venous cannulation involves introducing a catheter into a vein so that the catheter’s
tip lies with the venous system within the thorax. Generally, the optimal location of the
catheter tip is just superior to or at the junction of the superior vena cava and the right
atrium. When the catheter tip is located within the thorax, inspiration will increase or
decrease CVP, depending on whether ventilation is controlled or spontaneous.
Measurement of CVP is made with a water column (cm H2O), or, preferably, an electronic
transducer (mm Hg). The pressure should be measured during end expiration. Various sites
can be used for cannulation. All cannulation sites have an increased risk of line-related
infections the longer the catheter remains in place. Compared with other sites, the
subclavian vein is associated with a greater risk of pneumothorax during insertion, but a
reduced risk of other complications during prolonged cannulations (eg, in critically ill
patients). The right internal jugular vein provides a combination of accessibility and safety.
Left-sided internal jugular vein catheterization has an increased risk of pleural effusion and
chylothorax. The external jugular veins can also be used as entry sites, but due to the acute
angle at which they join the great veins of the chest, are associated with a slightly increased
likelihood of failure to gain access to the central circulation than the internal jugular veins.
Femoral veins can also be cannulated, but are associated with an increased risk of line-
related sepsis. There are at least three cannulation techniques: a catheter over a needle
(similar to peripheral catheterization), a catheter through a needle (requiring a large-bore
needle stick), and a catheter over a guidewire (Seldinger’s technique; Figure 6). The
overwhelming majority of central lines are placed using Seldinger’s technique. The following
scenario describes the placement of an internal jugular venous line. The patient is placed in
the Trendelenburg position to decrease the risk of air embolism and to distend the internal
jugular (or subclavian) vein. Venous catheterization requires full aseptic technique, including
scrub, sterile gloves, gown, mask, hat, bactericidal skin preparation (alcohol-based solutions
are preferred), and sterile drapes. The two heads of the sternocleidomastoid muscle and the
clavicle form the three sides of a triangle. A 25-gauge needle is used to infiltrate the apex of
the triangle with local anesthetic. The internal jugular vein can be located using ultrasound,
and we strongly recommend that it be used whenever possible. Alternatively, it may be
located by advancing the 25-gauge needle—or a 23-gauge needle in heavier patients—along
the medial border of the lateral head of the sternocleidomastoid, toward the ipsilateral
nipple, at an angle of 30° to the skin. Aspiration of venous blood confirms the vein’s location.
It is essential that the vein (and not the artery) be cannulated. Cannulation of the carotid
artery can lead to hematoma, stroke, airway compromise, and possibly death. An 18-gauge
thin-wall needle or an 18-gauge catheter over needle is advanced along the same path as the
locator needle, and, with the latter apparatus, the needle is removed from the catheter once
the catheter has been advanced into the vein. When free blood flow is achieved, a J wire
with a 3-mm radius curvature is introduced after confirmation of vein puncture. The needle
(or catheter) is removed, and a dilator is advanced over the wire. The catheter is prepared
for insertion by flushing all ports with saline, and all distal ports are “capped” or clamped,
except the one through which the wire must pass. Next, the dilator is removed, and the final
catheter is advanced over the wire. The guidewire is removed, with a thumb placed over the
catheter hub to prevent aspiration of air until the intravenous catheter tubing is connected
to it. The catheter is then secured, and a sterile dressing is applied. Correct location is
confirmed with a chest radiograph. The catheter’s tip should not be allowed to migrate into
the heart chambers. Fluid administration sets should be changed frequently, per your
medical center protocol. The possibility of placement of the vein dilator or catheter into the
carotid artery can be decreased by transducing the vessel’s pressure waveform from the
introducer needle (or catheter, if a catheter over needle has been used) before passing the
wire (most simply accomplished by using a sterile intravenous extension tubing as a
manometer). Alternatively, one may compare the blood’s color or PaO2 with an arterial
sample. Blood color and pulsatility can be misleading or inconclusive, and more than one
confirmation method should be used. In cases where transesophageal echocardiography
(TEE) is used, the guide wire can be seen in the right atrium, confirming venous entry.
The risks of central venous cannulation include line infection, blood stream infection,
air or thrombus embolism, arrhythmias (indicating that the catheter tip is in the right atrium
or ventricle), hematoma, pneumothorax, hemothorax, hydrothorax chylothorax, cardiac
perforation, cardiac tamponade, trauma to nearby nerves and arteries, and thrombosis.
Figure 6. Right internal jugular cannulation with Seldinger’s technique (see text).

Capnography
Indications & Contraindications.
Determination of end-tidal CO2 (EtCO2) concentration to confirm adequate
ventilation is mandatory during all anesthetic procedures, but particularly so for general
anesthesia. A rapid fall of EtCO2 is a sensitive indicator of air embolism, a major complication
of sitting craniotomies. There are no contraindications.

Techniques & Complications

Capnography is a valuable monitor of the pulmonary, cardiovascular, and anesthetic
breathing systems. Capnographs in common use rely on the absorption of infrared light by
CO2. As with oximetry, absorption of infrared light by CO2 is governed by the Beer–Lambert
law.
Nondiverting (Flowthrough)
Nondiverting (mainstream) capnographs measure CO2 passing through an adaptor
placed in the breathing circuit. Infrared light transmission through the gas is measured and
the monitor determines CO2 concentration. Because of problems with drift, older
flowthrough models self-zeroed during inspiration. Thus, they were incapable of detecting
inspired CO2, such as would occur with a breathing circuit malfunction (eg, absorbent
exhaustion, sticking unidirectional valves). The weight of the sensor causes traction on the
tracheal tube, and its generation of radiant heat can cause skin burns. Newer designs
address these problems.
Diverting (Aspiration)
Diverting (sidestream) capnographs continuously suctions gas from the breathing
circuit into a sample cell within the monitor. CO2 concentration is determined by comparing
infrared light absorption in the sample cell with a chamber free of CO2. Continuous
aspiration of anesthetic gas essentially represents a leak in the breathing circuit that will
contaminate the operating room unless it is scavenged or returned to the breathing system.
High aspiration rates (up to 250 mL/min) and low dead space sampling tubing usually
increase sensitivity and decrease lag time. If tidal volumes (Vt) are small (eg, pediatric
patients), however, a high rate of aspiration may entrain fresh gas from the circuit and dilute
EtCO2 measurement. Low aspiration rates (less than 50 mL/min) can retard EtCO2
measurement and underestimate it during rapid ventilation. New units autocalibrate, but
older units must be zeroed to room air and against a known CO2 concentration (usually 5%).
Diverting units are prone to water precipitation in the aspiration tube and sampling cell that
can cause obstruction of the sampling line and erroneous readings. Expiratory valve
malfunction is detected by the presence of CO2 in inspired gas. Although inspiratory valve
failure also results in rebreathing CO2, this is not as readily apparent because part of the
inspiratory volume will still be free of CO2, causing the monitor to read zero during part of
the inspiratory phase.

Figure 7. A nondiverting sensor placed in-line analyzes CO2 concentration at the sampling site.

Temperature
Indications
The temperature of patients undergoing anesthesia must be monitored.
Postoperative temperature is increasingly used as a quality anesthesia indicator.
Hypothermia is associated with delayed drug metabolism, increased blood glucose,
vasoconstriction, impaired coagulation, and impaired resistance to surgical infections.
Hyperthermia can likewise have deleterious effects perioperatively, leading to tachycardia,
vasodilation, and neurological injury. Consequently, temperature must be measured and
recorded perioperatively.
Contraindications
There are no contraindications, although a particular monitoring site may be
unsuitable in certain patients.
Techniques & Complications
Intraoperatively, temperature is usually measured using a thermistor or
thermocouple. Thermistors are semiconductors whose resistance decreases predictably with
warming. A thermocouple is a circuit of two dissimilar metals joined so that a potential
difference is generated when the metals are at different temperatures. Disposable
thermocouple and thermistor probes are available for monitoring the temperature of the
tympanic membrane, nasopharynx, esophagus, bladder, rectum, and skin. Infrared sensors
estimate temperature from the infrared energy that is produced. Tympanic membrane
temperatures reflect core body temperature; however, the devices used may not reliably
measure the temperature at the tympanic membrane. Complications of temperature
monitoring are usually related to trauma caused by the probe (eg, rectal or tympanic
membrane perforation). Each monitoring site has advantages and disadvantages. The
tympanic membrane theoretically reflects brain temperature because the auditory canal’s
blood supply is the external carotid artery. Trauma during insertion and cerumen insulation
detract from the routine use of tympanic probes. Rectal temperatures have a slow response
to changes in core temperature. Nasopharyngeal probes are prone to cause epistaxis, but
accurately measure core temperature if placed adjacent to the nasopharyngeal mucosa. The
thermistor on a pulmonary artery catheter also measures core temperature. There is a
variable correlation between axillary temperature and core temperature, depending on skin
perfusion. Liquid crystal adhesive strips placed on the skin are inadequate indicators of core
body temperature during surgery. Esophageal temperature sensors, often incorporated into
esophageal stethoscopes, provide the best combination of economy, performance, and
safety. To avoid measuring the temperature of tracheal gases, the temperature sensor
should be positioned behind the heart in the lower third of the esophagus. Conveniently,
heart sounds are most prominent at this location.

Urinary output
Indications
Urinary bladder catheterization is the only reliable method of monitoring urinary
output. Insertion of a urinary catheter is indicated in patients with congestive heart failure,
renal failure, advanced hepatic disease, or shock. Catheterization is routine in some surgical
procedures such as cardiac surgery, aortic or renal vascular surgery, craniotomy, major
abdominal surgery, or procedures in which large fluid shifts are expected. Lengthy surgeries
and intraoperative diuretic administration are other possible indications. Occasionally,
postoperative bladder catheterization is indicated in patients having difficulty voiding in the
recovery room after general or regional anesthesia.
Contraindications
Bladder catheterization should be done with utmost care in patients at high risk for
infection.
Techniques & Complications
Bladder catheterization is usually performed by surgical or nursing personnel. To
avoid unnecessary trauma, a urologist should catheterize patients suspected of having
abnormal urethral anatomy. A soft rubber Foley catheter is inserted into the bladder
transurethrally and connected to a disposable calibrated collection chamber. To avoid urine
reflux and minimize the risk of infection, the chamber should remain at a level below the
bladder. Complications of catheterization include urethral trauma and urinary tract
infections. Rapid decompression of a distended bladder can cause hypotension. Suprapubic
catheterization of the bladder with tubing inserted through a large-bore needle is an
uncommon alternative.
Clinical Considerations
An additional advantage of placing a Foley catheter is the ability to include a
thermistor in the catheter tip so that bladder temperature can be monitored. As long as
urinary output is high, bladder temperature accurately reflects core temperature. An added
value with more widespread use of urometers is the ability to electronically monitor and
record urinary output and temperature. Urinary output is a reflection of kidney perfusion
and function and an indicator of renal, cardiovascular, and fluid volume status. Inadequate
urinary output (oliguria) is often arbitrarily defined as urinary output of less than 0.5
mL/kg/hr, but actually is a function of the patient’s concentrating ability and osmotic load.
Urine electrolyte composition, osmolality, and specific gravity aid in the differential diagnosis
of oliguria.

Peripheral nerve stimulation

Indications
Because of the variation in patient sensitivity to neuromuscular blocking agents, the
neuromuscular function of all patients receiving intermediate- or long-acting neuromuscular
blocking agents should be monitored. In addition, peripheral nerve stimulation is helpful in
assessing paralysis during rapid-sequence inductions or during continuous infusions of short-
acting agents. Furthermore, peripheral nerve stimulators can help locate nerves to be
blocked by regional anesthesia.
Contraindications
There are no contraindications to neuromuscular monitoring, although certain sites
may be precluded by the surgical procedure. Additionally, atrophied muscles in areas of
hemiplegia or nerve damage may appear refractory to neuromuscular blockade secondary to
the proliferation of receptors. Determining the degree of neuromuscular blockade using
such an extremity could lead to potential overdosing of competitive neuromuscular blocking
agents.
Techniques & Complications
A peripheral nerve stimulator delivers current (60-80 mA) to a pair of either ECG
silver chloride pads or subcutaneous needles placed over a peripheral motor nerve. The
evoked mechanical or electrical response of the innervated muscle is observed. Although
electromyography provides a fast, accurate, and quantitative measure of neuromuscular
transmission, visual or tactile observation of muscle contraction is usually relied upon in
clinical practice. Ulnar nerve stimulation of the adductor pollicis muscle and facial nerve
stimulation of the orbicularis oculi are most commonly monitored (Fig. 8). Because it is the
inhibition of the neuromuscular receptor that needs to be monitored, direct stimulation of
muscle should be avoided by placing electrodes over the course of the nerve and not over
the muscle itself. To deliver a supramaximal stimulation to the underlying nerve, peripheral
nerve stimulators must be capable of generating at least a 50-mA current across a 1000-
Ωload. This current is uncomfortable for a conscious patient. Complications of nerve
stimulation are limited to skin irritation and abrasion at the site of electrode attachment.
Because of concerns of residual neuromuscular blockade, increased attention has been
focused on providing quantitative measures of the degree of neuromuscular blockade
perioperatively. Acceleromyography uses a piezoelectric transducer on the muscle to be
stimulated. Movement of the muscle generates an electrical current that can be quantified
and displayed. Indeed, acceleromyography can better predict residual paralysis, compared
with routine tactile train-of-four monitoring used in most operating rooms, if calibrated from
the beginning of the operative period to establish baselines prior to administration of
neuromuscular blocking agents.
Clinical Considerations
The degree of neuromuscular blockade is monitored by applying various patterns of
electrical stimulation. All stimuli are 200 µs in duration and of square-wave pattern and
equal current intensity. A twitch is a single pulse that is delivered from every 1 to every 10
sec (1–0.1 Hz). Increasing block results in decreased evoked response to stimulation. Train-
of-four stimulation denotes four successive 200-µs stimuli in 2 sec (2 Hz). The twitches in a
train-of-four pattern progressively fade as nondepolarizing muscle relaxant block increases.
The ratio of the responses to the first and fourth twitches is a sensitive indicator of
nondepolarizing muscle paralysis. Because it is difficult to estimate the train-of-four ratio, it
is more convenient to visually observe the sequential disappearance of the twitches, as this
also correlates with the extent of blockade. Disappearance of the fourth twitch represents a
75% block, the third twitch an 80% block, and the second twitch a 90% block. Clinical
relaxation usually requires 75% to 95% neuromuscular blockade. Tetany at 50 or 100 Hz is a
sensitive test of neuromuscular function. Sustained contraction for 5 sec indicates adequate
—but not necessarily complete—reversal from neuromuscular blockade. Doubleburst
stimulation (DBS) represents two variations of tetany that are less painful to the patient. The
DBS 3,3 pattern of nerve stimulation consists of three short (200-µs) high-frequency bursts
separated by 20 ms intervals (50 Hz) followed 750 ms later by another three bursts. DBS
3,2consists of three 200-µs impulses at 50 Hz followed 750 ms later by two such impulses.
DBS is more sensitive than train-of-four stimulation for the clinical (ie, visual) evaluation of
fade. Because muscle groups differ in their sensitivity to neuromuscular blocking agents, use
of the peripheral nerve stimulator cannot replace direct observation of the muscles (eg, the
diaphragm) that need to be relaxed for a specific surgical procedure. Furthermore, recovery
of adductor pollicis function does not exactly parallel recovery of muscles required to
maintain an airway. The diaphragm, rectus abdominis, laryngeal adductors, and orbicularis
oculi muscles recover from neuromuscular blockade sooner than do the adductor pollicis.
Other indicators of adequate recovery include sustained (≥5 s) head lift, the ability to
generate an inspiratory pressure of at least –25 cm H2O, and a forceful hand grip. Twitch
tension is reduced by hypothermia of the monitored muscle group (6%/°C). Decisions
regarding adequacy of reversal of neuromuscular blockade, as well as timing of extubation,
should be made only by considering both the patient’s clinical presentation and assessments
determined by peripheral nerve stimulation. Postoperative residual curarization (PORC)
remains a problem in postanesthesia care, producing potentially injurious airway and
respiratory function compromise. Reversal of neuromuscular blocking agents is warranted,
as is the use of intermediate acting neuromuscular blocking agents instead of longer acting
drugs.