CRITICAL CARE MONITORING Dr Smitha Bhat OBJECTIVES 1. WHY MONITORING? 2. WHAT MONITORING? 3. HOW MONITORING? 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 2 Why? Improves patient safety and outcomes Informs critical changes in patient health status Detects organ dysfunction Guides therapy 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 3 What monitoring? ■ Vital signs 1. Heart Rate 2. Blood Pressure 3. Respiratory Rate 4. Temperature ■ ■ ■ ■ CVP Pulse Oximetry ICP SvO2 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 4 Vital Signs and Physiotherapy Practice Reflect patient’s overall health & well-being. 29-08-2022 Help determine which treatment protocols to follow Information needed to make appropriate adjustments during patient care ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 5 Vital signs ■ Heart rate ■ Respiratory rate ■ Blood pressure ■ Temperature ■ Oxygen saturation? 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 6 Heart rate : 60 – 100/ minute Tachycardia > 100 ■ Infection ■ Pain ■ Hypovolemia, Bleed ■ Systemic vasodilation, hypotension ■ CO2 retention ■ Hyperthyroidism 29-08- Bradycardia < 60 ■ Raised ICP – Cushing’s triad ■ Hypothermia ■ Drugs ■ Hyperkalemia ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 7 Respiratory rate – 12-20 breaths/ minute ■ Sepsis ■ Diabetic ketoacidosis ■ Pneumonia ■ Pulmonary embolism ■ Pleural effusion ■ Asthma or COPD 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 8 Respiratory rate – why significant 29-08-2022 In the setting of cardiopulmonary illness, it can be a very reliable marker of disease activity. Rate of >25 breath/min / <8 breaths/min, or a decreasing /increasing RR can signify deterioration. Small change in a patient’s normal RR of 3-5 breaths/min could be an early sign of deterioration (Dougherty and Lister, 2015). Pulse oximetry is not a substitute for respiratory rate ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 9 Respiratory rate – clinical importance ■ Post-operative monitoring ■ Detecting complications such as pulmonary oedema associated with blood transfusion and administration of intravenous fluids ■ Identifying patients who are deteriorating ■ Evaluating response to treatment – for example use of opiates ■ Monitoring chronic lung disease such as chronic obstructive pulmonary disease ■ Monitoring patients receiving oxygen therapy 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 10 Arterial pressure - Invasive/ Noninvasive monitoring ■ MAP – indicator of tissue perfusion = ( SBP + 2 DBP)/3 ■ Radial/Femoral/brachial – direct, accurate, continuous, used for sampling too ■ Inaccurate marker of CO – SVR varies wildly in critically ill ■ Essential when inotropes used, and for anaesthesia in the critically ill 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 11 Hypertension Hypertensive urgency : BP > 180/110 mm Hg without TOD ■ Noncompliance with antihypertensive therapy ■ Use of sympathomimetics ■ Thyroid dysfunction ■ Anxiety and pain ■ Cushing's triad 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 12 Hypotension - < 90/60 mm Hg ■ ■ ■ ■ ■ ■ ■ Sepsis Blood loss Arrhythmias Valvular disease Tamponade Heart failure Medicines 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 13 Pulse Oximetry Non invasive measurement of arterial Hb saturation using finger/ear probe Beer Lambert law – optical absorbency proportional to thickness of medium and concentration of substance O2/deO2 blood differ in their capacities to absorb red/IR light Comparison of absorbances at 2 different wavelengths enables estimate of relative concentrations 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 15 Utility of pulse oximetry ■ Human eye's ability to detect hypoxemia is poor. ■ Central cyanosis occurs at an oxyhemoglobin saturation of about 75% ■ Pulse oximetry : convenient, noninvasive method to measure blood oxygen saturation continuously. ■ Helps to eliminate medical errors. ■ Sensitivity - 92% , specificity - 90% to detect hypoxia 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 16 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 17 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 18 Fallacies of pulse oximetry False low Affected by ■ Methemoglobinemia ■ Nail Polish ■ Sulfhemoglobinemia ■ Skin Pigmentation ■ High-intensity ambient lighting ■ Sickle hemoglobin ■ Excessive patient movement ■ Abnormal inherited forms of hemoglobin ■ Decreased perfusion ■ Severe anemia ■ Presence of abnormal hemoglobin, carboxyhemoglobin ■ Venous congestion ■ Reduced accuracy with saturations below 83% ■ Carboxyhemoglobin False high ■ High HbA1C1 1Pu LJ, Shen Y, Lu L, Zhang RY, Zhang Q, Shen WF. Increased blood glycohemoglobin A1c levels lead to overestimation of arterial oxygen saturation by pulse oximetry in patients with type 2 diabetes. Cardiovasc Diabetol. 2012 Sep 17;11:110. 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 19 Temperature Core Peripheral – affected by 1. Tympanic 2. Oesophageal 3. Bladder Gradient – effectiveness of resuscitation A. Vasoconstriction B. Cardiac Output 4. Rectal 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 20 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 21 Using the EWS ■ Guides the frequency of clinical monitoring ■ Score of 0 –monitor 12 hourly ■ Score of 1–4 – monitor 4–6 hourly ■ Score of 5–6 - monitor hourly ■ RED score - monitor continuously . ■ Continuous monitoring and recording of vital signs for those with score 7 or more 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 22 Urine output Cardiac Output Splanchnic Perfusion Renal Function 0.5 mL/Kg/hr 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 23 CVP monitoring ■ Useful for guiding fluid therapy ■ IJV/SV – Seldinger technique or USG guided ■ Transducer/manometer ■ Noted at end expiration ■ Response to 250-500 ml bolus 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 24 CVP – not infallible Single CVP measurement correlates poorly with intravascular volume1 Influenced by CVP not indicative of left heart filling pressure ■ Pt position ■ Venous tone ■ COPD ■ Intrathoracic pressure ■ PHT ■ Valvular disease ■ Mitral valve disease 1Barbeito A, Mark JB. Arterial and Central Venous Pressure Monitoring. Anesthesiology Clinics of North America. 2006 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 25 SvO2 and ScvO2 ■ SvO2 – amount of oxygen left after tissues extract required O2 – 60-80% ■ Increased O2 extraction if O2 reaching tissues less, or O2 demand increases ▷ ↓ SvO2 ■ DO2 = HR x SV x Hb X SaO2 ■ CO ↑ ▷ Tissue O2 extraction ↑ ▷Anaerobic met. ↑ 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 26 Interpretation of SvO2 CO not adequate to meet tissue O2 needs 29-08-2022 VO2 increased without parallel increase in DO2 Return to ή SvO2 ▷ patient improving ↑ SvO2 but ↑ lactate –ominous ▷ tissues unable to extract O2 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 May be used to titrate PEEP 27 Intracranial pressure 3 – 15 MM HG NORMAL 29-08-2022 > 20 ELEVATED ICP TRAUMATIC BRAIN INJURY LARGE ISCHEMIC STROKE ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 INTRACEREBRAL HAEMORRHAGE 28 Monitoring equipment has not yet reached aviation industry standards Moving from descriptive variables to monitoring organ function To Reflect On: Which variables should be monitored? What monitoring improves clinical decision making ? Acquisition of novel monitoring devices irrelevant without adequate & regular training 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 29 To remember MONITORING IS NOT INFALLIBLE AND SHOULD BE USED AS AN ADJUNCT TO CLINICAL EXAMINATION 29-08-2022 BE AWARE OF PITFALLS IN INTERPRETATION OF MONITORED DATA ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 30 In summary ■ Monitoring of vital signs and other parameters crucial clues to patient status, change in condition, and response to therapy ■ Heart rate, blood pressure, respiratory rate, temperature, pulse oximetry, ICP, CVP ■ Collecting data is not sufficient – analysis and interpretation of data crucial 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 31 29-08-2022 ESSENTIALS IN CRITICAL CARE PHYSIOTHERAPY FMMC DECEMBER 2019 32
