Monitoring in Anesthesia

Dr. Med. Khaled Radaideh

Department of Anesthesiology
Faculty of Medicine
Jordan University of Science and Technology

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Monitoring in Anesthesia
OBJECTIVES:
1. Guidelines to the practice of anesthesia and patient
monitoring
2. Elements to monitor (Anesthesia depth, Oxygenation,

Ventilation, Circulation, Temperature)

2.1. ECG
2.2. Pulse Oximetry ( Function, Values, Limitations)
2.3. Blood Pressure (methods, indications, limitations, Insertion sites,
values)
2.4. central venous line and pressure (methods, indications,
limitations, Insertion sites and it's advantages, Complications, values)
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Monitoring in Anesthesia
OBJECTIVES:
2.5. Capnography and EtCO2 (Uses, Measurement, values, factors
affecting EtCO2)
2.6. Cyanosis
2.7. The oxyhemoglobin dissociation curve (interpretation, causes of
Left and right shifting , key values, O2-Content of Blood)
2.8. Temperature ( Methods, Values, sites)

3. Normal values for a healthy adult undergoing anesthesia

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Guidelines to the practice of anesthesia and

patient monitoring:

Monitoring in the Past

Visual monitoring of
respiration and
overall clinical
appearance
Finger on pulse
Blood pressure
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Guidelines to the practice of anesthesia and

patient monitoring:

1. Qualified anesthesia personnel shall be

present in the room throughout the conduct of

all general anesthetics, regional anesthetics
and monitored anesthesia care.
2. A completed pre-anesthetic checklist.
(history, physical exam, lab investigations,
NPO policy)

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Guidelines to the practice of anesthesia and

patient monitoring:

3. An anesthetic record. ( In general, major

regional anesthesia, or monitored IV conscious

sedation HR and BP should be measured every
5 min. Also time, dose and route of drugs and
fluids should be charted )

4. During all anesthetics, the patients

oxygenation, ventilation, circulation and

temperature shall be continually evaluated.

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

MONITORING
HR
O2 sat
RR

BP

Feb 14, 2015

Temp

MAP
Dr. Med. Khaled
Radaideh, Facharzt

Elements to Monitor :
I. Anesthetic Depth:
Patients with local or regional anesthesia provide verbal
feedback regarding well being.
Onset of general anesthesia signaled by lack of response to
verbal commands, in addition to loss of blink reflex to light
touch.
Inadequate anesthesia can be signaled by : Facial grimacing
or movement of arm or leg. But with muscle relaxants ( fully
paralysis), it can be signaled by : Hypertension, tachycardia,
tearing or sweating.
Excessive anesthesia can be signaled by : Cardiac
depression, bradycardia, and Hypotension. And also may
result in hypoventilation, hypercapnia and hypoxemia when
muscle relaxants is not given.

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Elements to Monitor :
II. Oxygenation:
Clinically, monitored by patient color ( with adequate
illumination ) and pulse oximetry.
Quantitavely monitored by using oxygen analyzer, equipped
with an audible low oxygen concentration alarm.

III. Temperature
Continuous temperature measurements monitoring is
mandatory if changes in temperature are anticipated or
suspected.

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

Elements to Monitor :
IV. Circulation:
Clinically, monitored by pulse palpation, heart auscultation
and monitoring intra-arterial pressure or oximetry.
Quantitavely using ECG signals and arterial blood pressure
measurements every 5 min.

V. Ventilation
Clinically, monitored through a correctly positioned
endotracheal tube, also observing chest excursions, reservoir
bag displacement, and breath sounds over both lungs.
Quantitavely by ETCO2 analysis, equipped with an audible
disconnection alarm.
Arterial blood gas analysis for assessing both oxygen and
ventilation.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring:

Electrocardiogram ECG:

A 3 or 5 lead electrode system is used for

ECG monitoring in the OR.
The 3 lead system has electrodes positioned
on the right arm, left arm and chest position.
( placed in the left anterior axillary line at
the 5th interspace, referred to as V5 ). Lead 2
is usually monitored by this system.
The 5 lead system adds a right leg and left
leg electrodes, which allows monitoring v1,
v2, v3, AVR, AVL, AVF and V5.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring:

Electrocardiogram ECG:

Identification of P waves in lead 2 and its

association with the QRS complex is useful in
distinguishing a sinus rhythm from other
rhythms.
Analysis of ST segment is used as an indicator
of MI. ( Dep.-ischemia / elev.-infarction )
Over 85% of ischemic events can be detected
by monitoring ST seg. of leads 2 and V5.

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring:

Pulse Oximetry:

Allows beat to beat analysis of oxygenation.

Depends on differences in light absorption between
oxyHb and deoxyHb.
Red and Infra-red light frequencies transmitted
through a translucent portion. (finger-tip or earlobe)
Microprocessors then analyze amount of light
absorbed by the 2 wavelengths, comparing
measured values, then determining concentrations
of oxygenated and deoxygenated forms. (oxy- and
deoxy-)
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

13

Monitoring:

Pulse Oximetry:

After all data is processed, oxygen saturation can be

calculated.
Pulse plethysmograph (visual analysis of pulse waveform),
while an audible form (auditory assessment of oxygenation
status).
Pulse oximetry (SpO2) measures oxy-, deoxy-, met-, and
carboxyHb.
CO poisoning gives an overestimation of the true O2
saturation(SaO2). E.g. Burn victims.
Inaccurate measurements seen in poor tissue perfusion
(shock or cold extremities), movement, dysrhythmias, or
when electrical interference is present (surgical cautery unit).
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

1. Simplest method of BP measurement,

estimating the SBP, is by palpating the return
of arterial pulse as cuff is deflated.

2. auscultation of the Kortokoff sounds on deflation

(providing both SBP and DBP)
Mean Arterial Pressure (MAP) = DBP + 1/3(SBP DBP)

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

3. Automated non-invasive BP measurements.

METHODOLOGY: a microprocessor controlled oscillometer
(Dinamap) which is used routinely intraoperatively. It
allows automatic inflation of the BP cuff at preset time
intervals, sending readings into a pressure transducer that
digitalizes them. This technique gives rapid, accurate ( 9
mmHg) measurements of SBP, DBP, MAP and HR several
times a minute. LIMITATIONS: Errors occur due to
movements, arrhythmias or BP fluctuations due to
respiration. 3 5 minutes intervals is recommended to
prevent compressive peripheral nerve injury due to repeated
rapid measurements.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring:

Blood Pressure BP:

o Methods of BP measurement:

4. Invasive BP measurements. (Arterial

BP):
Indications:

Rapid moment to moment BP changes

Frequent blood sampling
Major surgeries (cardiac, thoracic, vascular)
Circulatory therapies: vasoactive drugs, deliberate
hypotension
Failure of indirect BP: burns, morbid obesity
Sever metabolic abnormalities
Major trauma
The radial artery at the wrist is the most common
site for an arterial catheter. Alternatives are
femoral, brachial and dorsalis pedis.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

17

Central Venous line and Pressure (CVP)

Catheter inserted into the SVC
providing an estimate of the right
atrial and ventricular pressures.
Serial CVP measurements are
more useful than a single value in
order to assess blood volume,
venous tone and right ventricular
performance. HR, BP and CVP
response to a volume infusion
(100 500 ml) is also a useful test
of right ventricular performance.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Central Venous line and Pressure (CVP)

Indications:
CVP monitoring provides Right
Atrial and Right Ventricle pressures
Advanced Cardiopulmonary disease
+ major operation
Secure vascular access for drugs
Secure access for fluids + traumatic
pts
Aspiration of entrained air: sitting
craniotomies
Inadequate peripheral IV access
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Central Venous Line:

PERFORMANCE of Right Internal Jugular Vein
Internal jugular (Int. Jug.) vein lies in
groove between sternal and clavicular
heads of sternocleidomastoid muscle
It is lateral and slightly anterior to
carotid artery
Aseptic technique, head down
Insert needle towards ipsilateral nipple
Seldinger method: 22 G finder; 18 G
needle, guide-wire, scalpel blade, dilator
and catheter
Observe ECG and maintain control of
guide-wire
Ultrasound guidance; Chest-Xray post
insertion.
Feb 14, 2015
Dr. Med. Khaled Radaideh, Facharzt

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Advantages of Right Int. Jug. vein

Consistent, predictable anatomic location

Readily identifiable landmarks
Short straight course to Superior Vena Cava
Easy access for anesthesiologist at patients
head
High success rate, 90-99%

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

21

Complications of Central lines (jugular):

Bleeding
Injury to surrounding
structures as carotid artery
Pneumothorax
Arrhythmia

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Central Venous line Alternative

Sites
Subclavian vein:
Easier to insert versus Int. Jug. vein
Better patient comfort v. Int. Jug.
Higher Risk of pneumothorax- 2%

External jugular:

Easy to cannulate if visible.

no risk of pneumothoroax,
high risk or bleeding
20%: cannot access central circulation

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Central Venous Pressure (CVP )

Monitoring
Reflects pressure at junction of vena cava + RA
CVP is driving force for filling RA + RV
CVP provides estimate of:
Intravascular blood volume
RV preload
Trends in CVP are very useful
Measure at end-expiration
Central Venous Pressure (CVP): 1-10 mmHg

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Capnography and EtCO2

Capnometry: is the
numerical measurement
of CO2 concentration
during inspiration and
expiration.
Capnogram: refers to the
continuous display of the
CO2 concentration
waveform sampled from
the patients airway
during ventilation.
Capnography: is the
continuous monitoring of
a patients capnogram.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Capnography and EtCO2

End-tidal CO2 monitoring is standard for all patients undergoing
GA with mechanical ventilation.
It is an important safety monitor and a valuable monitor of the
patients physiologic status, and it has been an important factor in
reducing anesthesia-related mortality and morbidity.
Co2 monitoring is considered the best method for verifying
successful intubation and extubation procedures.
It helps in assessment of the adequacy of ventilation and an
indirect estimate of PaCO2.
Also it aids in diagnosis of PE, recognition of a partial airway
obstruction, and indirect measurement of airway reactivity
(bronchospasm).
ETCO2 levels have also been used to predict outcome of
resuscitation.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Capnography and EtCO2

Measurement of ETCO2
Sampling the patients respiratory gases near the airway.
Using infra-red gas analysis or mass spectrometry on the
values and concentrations obtained.
Provided that when sampling, inspired CO 2 value should be
near zero. (i.e. ETCO2 value is a function of CO2 production,
alveolar ventilation and pulmonary circulation; excluding
inspired CO2).
During general anesthesia, with absence of ventilation
perfusion abnormalities, difference between PaCO 2 and ETCO2
is about 5 mm Hg (PaCO2 = 40 mmHg, ETCO2 = 35 mmHg)
Increases or decreases in ETCO2 values maybe the result of
increases or decreases in production and elimination.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Capnography and EtCO2 Factors affecting

ETCO2:
Increased ETCO2

Decreased ETCO2

Changes in CO2 Production

Hyperthermia
Sepsis
Thyroid storm
Malignant Hyperthermia
Muscular Activity

Hypothermia
Hypometabolism

Changes in CO2 Elimination

Hypoventilation
Rebreathing
Partial airway obstruction
Exogenous CO2 absorption
(laparoscopy)

Hyperventilation
Hypoperfusion
Embolism

Transient increases in ETCO2 may be noted after: IV bicarbonate

administration, release of extremity tourniquets, or removal of
vascular cross-clamps.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Cyanosis:
Defined as the presence of 5 gm/dL of deoxygenated
hemoglobin (deoxy Hb).
i.e. Hb level = 15 gm/dL, 5 gm/dL release O 2
which leaves 10 gm/dL of oxyhemoglobin
SaO2 = OxyHb / (OxyHb + DeoxyHb)
= 10 / (10 + 5)
= 66%
SAO2 of 66% corresponds to PaO2 of 35mmHg.

In anemic patients the oxygen tension at which cyanosis

is detectable will be even lower.
i.e. Hb level = 10 gm/dL, 5 gm/dL release O 2
SaO2 = OxyHb / (oxyHb + DeoxyHb)
= 5 / (5 + 5)
= 50%
SAO2 of 50% corresponds to PaO2 of only 27 mmHg.

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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The oxyhemoglobin dissociation curve

It is a sigmoid curve that describes the relationship between

oxygen tension (PaO2) and binding (SpO2).
When PaO2 is low, the hemoglobin affinity to oxygen falls
rapidly , explaining the sharp sloping .(PaO2< 60 mmHg)
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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The oxyhemoglobin dissociation curve

A decrease in PaO2 of less than 60 mmHg (corresponding to SpO 2 90 %) results
in a rapid fall in the oxygenation saturation.
The lowest acceptable O2 saturation level is 90%.

Left And Right Shifts of the

Oxyhemoglobin Dissociation Curve
Right

Left

Decreased affinity of Hb for O2.

Increased affinity of Hb for O2.

Causes:
Inc. PCO2
Hyperthermia
Acidosis
Increased altitude
Increased 2,3-DPG
Sickle Cell Anemia
Inhalational anesthetics

Causes:
Dec. PCO2
Hypothermia
Alkalosis
Fetal hemoglobin
Decreased 2,3-DPG
Carboxyhemoglobin
Methemoglobin

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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The oxyhemoglobin dissociation curve

Key Values:
a. At PO2 100 mmHg, Hb 100% saturation.
b. At PO2 40 mmHg, Hb 75% saturation.
c. At PO2 27 mmHg, Hb 50% saturation.

Oxygen content of blood:

is the total amount of O2 carried in blood, including bound and
dissolved O2.
O2 content = (O2-binding capacity * % saturation) + O 2 dissolved
O2-binding capacity = maximal amount of O2 bound to Hb at 100 % sat.

The dissolved O2 isnt measured by oximetry but by blood gas

analysis.
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring Temperature
Objective

aid in maintaining appropriate body temperature

Application

readily available method to continuously monitor

temperature if changes are intended, anticipated or
suspected

Methods

thermostat
temperature sensitive chemical reactions

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring Temperature
Potential heat loss or risk of hyperthermia
necessitates continuous temperature
monitoring
Normal heat loss during anesthesia averages
0.5 - 1 C per hour, but usually not more that 2
-3C
Temperature below 34C may lead to
significant morbidity
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring Temperature
Hypothermia develops when thermoregulation
fails to control balance of metabolic heat
production and environment heat loss
Normal response to heat loss is impaired
during anesthesia
Those at high risk are elderly, burn patients
neonates, spinal cord injuries

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring Temperature

Hyperthermia Causes
Malignant hyperthermia
Endogenous pyroxenes (IL1)
Excessive environmental warming
Increases in metabolic rate secondary to:

Thyrotoxicosis
Pheochromocytoma

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Monitoring Temperature
Monitoring Sites

Tympanic
Esophagus
Rectum
Nasopharynx

Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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Normal values for a healthy adult

undergoing anesthesia
Systolic Blood Pressure
Diastolic Blood Pressure
Heart Rate
Respiratory Rate
Oxygen sat. by oximetry
End Tidal Carbon Dioxide
tension
Skin appearance
Color
Temperature
Urine Production

SBP
DBP
HR
RR
SpO2
ETCO2

CVP
Central Venous Pressure
PAP
Pulmonary Artery Pressure
(mean)

Pulmonary
Capillary
Wedge
Feb 14, 2015
Dr. Med. Khaled Radaideh, Facharzt
PCWP
Pressure

85
160
50 95
50
100
8 20
95
100
33 45
warm,
dry
pink
36
37.5
>= 0.5

mmHg
mmHg
bpm
rpm
%
mmHg

1 10
10 20
5 15
75

mmHg
mmHg
mmHg
%

C
ml.kg1
.min-1
O

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Monitoring in Anesthesia
Dr. Med. Khaled Radaideh

THANK YOU
Department of Anesthesiology
Faculty of Medicine
Jordan University of Science and
Technology
Feb 14, 2015

Dr. Med. Khaled Radaideh, Facharzt

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